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NEURASTHENIA. 


DEGENERATION  IN  FAMILIES  : 

OBSERVATIONS  IN  A  LUNATIC  ASYLUM. 

BY 

FR.  LANGE,  M.D. 

Medical   Superintendent  of  the  Lunatic  Asylum,  near 
Middlefort,  Denmark. 

Authorized   Translation  from   the  Danish 
By  C.  CHR.  SONNE. 

CROWN  OCTAVO.      202  PAGES.      CLOTH. 

Price  3/6  net 
($1.25) 


NEURASTHENIA 


BY 


GILBERT  BALLET 

Professeur  agrdgd  a  la  Faculte  de  Me"decine  de  Paris 

Mgdedn  de  1'  Hotel  Dieu 
President  de  la  Societe  de  Neurologie 


TRANSLATED    FROM    THE   THIRD   FRENCH    EDITION    BY 

P.    CAMPBELL   SMITH,    M.D. 


ILLUSTRATED    WITH    SEVEN    FIGURES. 


PAUL    B.    HOEBER 

69  EAST  59TH  STREET 

NEW   YORK 

1909 


AUTHOR'S   PREFACE  TO  THE  THIRD 
FRENCH    EDITION. 


The  first  and  second  editions  of  this  work  bore 
the  name  of  our  dear  and  lamented  teacher,  Pro- 
fessor Proust,  as  well  as  our  own.  In  preparing 
this  third  edition  we  have  been  deprived  of  his 
valuable  collaboration,  which  we  are  desirous  of 
commemorating. 

The  hygiene  of  the  Neurasthenic  is  the  same 
to-day  as  yesterday,  and  we  have  had  no  funda- 
mental modifications  to  make  in  our  original  work. 
We  have  thought  it  necessary  however  to  render 
it  more  complete  on  certain  points.  In  this 
edition  will  be  found  some  new  sections  which 
were  not  in  those  that  preceded  it.  The  word 
Neurasthenia  is  one  of  those  that  are  so  much 
abused,  by  being  employed  wrongly  and  without 
discernment,  that  we  have  deemed  it  useful  to 
render  its  clinical  signification  more  precise,  and 
to  devote  several  pages  to  the  diagnosis  of  the 
affections  to  which  it  is  unfittingly  applied.  We 
have  made  some  necessary  additions  to  the  chap- 
ters on  psychotherapeutics  and  on  the  dietetic 
regime  of  Neurasthenics.  We  have  thought  that 

Neurasthenia.  A* 


vi.  PREFACE. 

it  is  not  superfluous  to  mention  certain  new 
developments  in  the  hygiene  and  treatment  of  the 
intestinal  disorders  that  are  so  frequent  in 
nervous  asthenia.  Treatment  and  hygiene  are  so 
closely  related  that  it  is  very  difficult  to  separate 
them,  and  it  would  be  arbitrary  to  try  to  do  so. 
Such  as  it  is,  to-day  as  yesterday,  this  little  book 
does  not  claim  to  be  a  dogmatic  treatise  on 
Neurasthenia,  but  an  abstract  in  which  we  have 
tried  to  set  forth  briefly  and  as  clearly  as  possible 
the  rules  and  facts  which  should  guide  the 
clinician  in  practice.1 

1  The  penultimate  sentence  of  the  above  refers  to  the  fact  that 
the  title  of  the  original  is  "  L'Hygiene  du  Neurasthenique,"  the 
book  forming  one  of  a  series  of  works  on  hygiene.  But,  as  the 
author  points  out,  he  does  not  confine  himself  to  hygiene,  and  it  is 
thought  that  the  English  title  expresses  better  the  scope  of  the 
work. — Trans. 


AUTHORS'  PREFACE  TO  FIRST 
EDITION. 


It  is  not  our  intention  to  set  forth  in  this  work 
a  full  account,  with  illustrative  cases,  of  Neuras- 
thenia and  its  treatment.  This  affection  has  been 
the  subject  of  many  descriptions  since  the  truly 
fundamental  picture  of  it  drawn  by  Beard.  The 
American  author  was  not  indeed  the  first  to 
observe  and  to  isolate  Neurasthenia,  since  its 
principal  symptoms  are  found  in  the  Spinal 
Irritation  of  Franck,  the  Proteiform  Neuralgia  of 
Cerise,  the  Nervosity  of  Bouchut,  and  the  Cerebro- 
cardiac  Neuropathy  of  Krishaber;  but  Beard's 
monograph  had  the  merit  of  being  more  synthetic 
and  more  complete  than  its  predecessors,  and 
above  all  it  had  the  good  fortune  to  appear  at  a 
propitious  moment.  While  Nervous  Exhaustion 
seemed  to  become  multiplied  in  America  and 
naturally  drew  the  attention  of  neuro-pathologists 
(Weir  Mitchell  after  Beard),  in  the  old  world  the 
new  conditions  created  by  the  exigencies  of 
modern  life  promoted  the  recrudescence  of  the 
Neurosis  from  Exhaustion  of  which  Monneret 
had  already  spoken. 


viii.  PREFACE. 

It  is  an  of  ten -repeated  commonplace  to-day, 
that  in  consequence  of  the  progress  of  civilisa- 
tion and  the  increase  in  cerebral  activity  entailed 
thereby,  neuroses  in  all  their  forms  have  become 
much  more  common  than  formerly.  This  state- 
ment deserves  the  trouble  of  verification,  and  it 
must  be  confessed  that  precise  observations  for 
making  this  verification  with  some  degree  of 
exactitude  are  still  wanting.  Besides,  even  if 
the  pessimists  were  right,  it  would  not  thereby 
be  proved  that  the  entire  increase  in  the  number 
of  nervous  complaints  must  be  ascribed  to  the 
refinements  of  civilisation  and  the  new  require- 
ments that  our  brains  have  to  satisfy.  Intoxica- 
tions, including  the  least  refined  of  them, 
alcoholic  poisoning,  might  rightly  claim  a  large 
share  in  the  determining  causes  of  the  nervous 
disorders  that  seem  to  be  special  to  our  epoch. 

However  this  be,  notwithstanding  the  reserve 
with  which  scientific  prudence  enjoins  us  to 
receive  unproved  assertions,  we  cannot  help 
thinking  that,  in  some  circles  at  least,  Neuras- 
thenia is  commoner  than  it  was  sixty  years  ago. 
In  any  case  we  recognise  it  better,  and  we  give 
it  a  name  when  we  meet  it;  facts  that  may 
suffice  in  some  measure  to  explain  how  it  seems 
much  more  frequent  to  us  than  at  the  time  when 
it  was  unnamed,  or,  what  comes  to  the  same 
thing,  when  it  had  too  many  names.  Whether  its 
frequency  has  increased  at  all,  or  not  at  all, 


PREFACE.  ix. 

moderately  or  a  great  deal,  this  much  is  certain, 
that  Neurasthenia  is  a  common  complaint ;  and 
this  is  enough  to  explain  the  favour  with  which 
Beard's  description  was  greeted.  Charcot  in 
France  ensured  its  recognition  and  many  others 
followed,1  so  much  so  that  at  the  present  moment 
Neurasthenia,  which  was  almost  unknown  thirty 
years  ago,  has  more  than  assumed  its  rightful 
place  in  clinical  medicine,  and  has  become  a 
convenient  name  which  too  often  covers 
erroneous  or  incomplete  diagnoses. 

Hence  it  will  not  cause  surprise  that  in  a  work 
devoted  to  the  laying  down  of  the  hygienic 
measures  requisite  for  the  prophylaxis  and 
treatment  of  Neurasthenia,  we  have  judged  it 

1  The  following  are  the  principal  works  or  complete  descriptions 
to  which  Neurasthenia  has  given  origin. 

Beard,  A  Practical  Treatise  on  Nervous  Exhaustion,  its  Causes, 
Symptoms  and  Sequences,  New  York,  1880. — Axenfeld  et  Huchard, 
Traits  des  Nevroses ;  Paris,  1883. — Charcot,  Lemons  cliniques,  and 
passim. — Ziemssen,  Die  Neurasthenic  und  ihre  Behandlung,  Leipzig, 
1887  (translated  for  the  New  Sydenham  Soc.,  1894) .— Bouveret, 
La  Neurasthenic,  2nd  ed. ;  J.  B.  Bailliere,  Paris,  1881. — Mathieu, 
Neurasthenic,  collection  Charcot-Debove. — Levillain,  La  Neuras- 
thenic, Paris,  1891. — Dutil,  art.  Neurasthenic,  in  Traits  de  medecine, 
Paris,  1894. — F.  M  tiller,  Handbuch  der  Neurasthenic,  Leipzig,  1893. 
— Gilles  de  la  Tourette,  Lcs  stats  neurasthsniques,  J.  B.  Bailliere, 
Paris,  1900. — Maurice  de  Fleury,  Les  grands  symptomes  neuras- 
theniques, F.  Alcan,  Paris,  1901. — Brissaud,  art.  Neurasthenic,  in 
Brouardel  and  Gilbert's  Traits  de  medecine,  Paris,  1902. — Godlewski, 
Les  neurasthenics,  Maloine,  Paris,  1904. 

[The  almost  classical  work  by  Dr.  Weir  Mitchell — Fat  and  Blood, 
8th  ed.,  1900 — should  be  mentioned.  Other  monographs  in  English 
are  On  Brain  and  Nerve  Exhaustion  by  Dr.  T.  S.  Dowse,  4th  ed., 
1894,  and  Clinical  Lectures  on  Neurasthenia  by  Dr.  T.  D.  Savill,  3rd 
ed,,  1906.  There  are  also  very  instructive  articles  by  Prof.  Dana  in 
the  Twentieth  Century  Practice  of  Medicine,  vol.  x,  and  by  Prof. 
Clifford  Allbutt  in  his  System  of  Medicine,  vol.  viii.  The  important 
papers  by  Playfair  in  Brit.  Med.  Journ,  1882,  and  Page  in  Med. 
Times  and  Gazette,  1885  (reprinted)  must  also  be  referred  to. — Trans.] 


x.  PREFACE. 

necessary  to  describe  the  affection,  and  to  point 
out  the  various  forms,  both  the  commoner  and  the 
rarer,  that  it  is  clinically  found  to  assume.  Again, 
prophylaxis  presupposes  a  knowledge  of  all  the 
possible  causes  of  the  affection ;  hence  it  has  been 
necessary  for  us  to  make  a  short  study — or  at 
least  a  detailed  enumeration — of  these  causes. 

Hygienic  measures,  which  would  suffice  to 
prevent  Neurasthenia  if  they  were  rigorously 
applied  and,  we  must  add,  if  they  were  always 
applicable,  usually  suffice  also  to  cure  it  when  the 
complaint  is  capable  of  cure.  Without  wishing 
to  abolish  treatment  by  medicines,  we  venture  to 
say  that  on  the  whole  more  harm  than  good  has 
been  done  by  drugs  both  to  those  threatened  by 
Neurasthenia  and  to  those  already  attacked.  If 
we  could  draw  up  a  schedule  of  the  evil  results 
of  so-called  tonic  and  "  building-up  "  medicines, 
of  the  different  hypnotics,  in  short  of  all  the 
pharmaceutical  products  that  overload  the  more 
or  less  well-advised  forms  of  treatment  that  have 
entered  into  daily  use,  we  should  ask  if  neuras- 
thenics were  the  debtors  or  the  victims  of  medi- 
cine. Was  it  not  Montaigne  who  said  that  the 
physicians  of  his  time,  to  avoid  curing  the  brain 
at  the  expense  of  the  stomach,  injured  the 
stomach  and  made  the  brain  worse,  "  by  their 
confused  multitude  of  discordant  drugs  "  ?  Do 
not  let  us  imitate  the  bad  practitioners  of  that 
age,  and  do  not  let  us  forget  that  a  medical  man 


PREFACE.  xi. 

would  be  ignorant  of  his  duties  if  he  believed 
them  to  be  limited  to  prescribing  medicines ;  good 
moral  and  physical  hygiene,  a  well-conceived 
dietary,  the  action  of  suggestion  in  the  shape  of 
advice  and  encouragement,  these  as  a  rule  do 
more  for  the  neurasthenic  than  complex  pre- 
scriptions that  are  often  useless  and  sometimes 
harmful.  This  is  enough  to  show  the  interest 
presented  by  the  subject  on  which  we  are  now 
about  to  enter. 


CONTENTS. 


PAGE 

AUTHOR'S  PREFACE  TO  THIRD  EDITION-        -  v. 

AUTHORS'  PREFACE  TO  FIRST  EDITION  -        -  vii. 

TRANSLATOR'S  INTRODUCTION  -  xv. 

PART   I. 

DEFINITION  AND  NATURE  OF  NEURASTHENIA-  1 

PART   II. 

THE  CAUSES  OF  NEURASTHENIA.      WHY  AND 

HOW  ONE  BECOMES  NEURASTHENIC          -  6 

CHAPTER  1.     General  Causes         •  6 

CHAPTER  2.     Special  Causes  -        -  12 

CHAPTER  3.     Exciting  Causes        -  17 

PART   III. 

SYMPTOMS  AND  CLINICAL  FORMS  OF  NEURAS- 
THENIA    38 

CHAPTER  1.     General  Picture        -  38 
CHAPTER  2.     Leading    Symptoms 

or  Stigmata  of  Neurasthenia  -  44 

CHAPTER  3.     Secondary  Symptoms  75 

CHAPTER  4.     Forms       -r        ^       -  90 

CHAPTER  5.     Differential  diagnosis  105 

Neurasthenia.  B 


xiv.  CONTENTS. 

PART   IV.  PAGE 

ETIOLOGY    -  -        -     126 

PART  V. 

PROPHYLAXIS        -                 -                          -  141 

CHAPTER  1.     Generalities      -        -  141 

CHAPTER  2.     Physical  Education  -  146 

CHAPTER  3.     Moral  Education       -  159 

CHAPTER  4.     Prophylaxis  in  Adults  171 

PART  VI. 

TREATMENT  -  -     175 

CHAPTER  1.     Generalities      -        -     175 
CHAPTER  2.     General  Treatment  of 
Neurasthenics.     Psychothera- 
peutics   -  -     178 

CHAPTER  3.     Diet-  -    209 

CHAPTER  4.     Hydrotherapeutics    -     308 
CHAPTER  5.     Climatic    Treatment. 

Choice  of  a  Health-Resort      -    322 
CHAPTER  6.     Exercise   and    Gym- 
nastics   -  -    339 

PART  VII. 
TREATMENT   OF   SOME    CLINICAL    FORMS    OF 

NEURASTHENIA       -  -  346 

CHAPTER  1.     Neurasthenia  of 

Women.   Weir  Mitchell's  Sys- 
tem of  Treatment   -        -        -    346 
CHAPTER  2.     Treatment  of  Genital 

Neurasthenia-        -  363 


TRANSLATOR'S   INTRODUCTION. 

To  those  who  have  read  Professor  Ballet's 
work  in  the  original,  a  translation  will  need  no 
apology — save  for  its  own  defects.  Striking 
features  of  the  book  are  its  eminently  practical 
character  and  its  clearness  of  exposition ;  in 
addition  to  these  qualities  the  work  shows  wide 
experience  and  great  precision  of  observation  on 
the  part  of  the  author,  who  has  succeeded  in 
drawing  a  vivid  picture  of  the  complaint,  and  in 
laying  down  the  details  of  treatment  with  fulness 
and  lucidity.  The  third  French  edition,  which 
appeared  last  year,  and  from  which  the  present 
English  edition  has  been  taken,  contains  a  great 
deal  of  new  matter;  a  valuable  chapter  on 
differential  diagnosis  has  been  added,  and  the 
sections  on  treatment  have  been  rendered  even 
more  complete. 

Something  additional,  however,  may  be  said  on 
the  question  of  pathogeny.  The  name  Neurasthenia 
is  commonly  applied,  even  by  medical  men,  to  two 
different,  though  closely  related,  conditions :  one, 
the  disease  of  adults  which  forms  the  subject  of 
this  work;  the  other  a  state  of  languor,  usually 
congenital  but  sometimes  arising  in  infancy, 


xvi.    TRANSLATOR'S  INTRODUCTION. 

which  I  have  elsewhere  called  Neurasthenia 
Minor,1  and  which  has  been  described  as  being 
"born  tired."  Inquiry  will  show  that  the  former 
is  nearly  always,  in  this  country  at  any  rate,  a 
mere  exacerbation  of  the  latter,  its  symptoms 
being  partly  the  same,  and  those  that  are  new 
being  due  to  an  aggravation  of  some  of  the 
more  fundamental  pathological  conditions  of  the 
congenital  complaint  by  worry  or  some  other 
fatiguing  influence.  As  to  the  nature  of  the 
minor  disorder,  the  more  fundamental  pathologi- 
cal conditions  just  referred  to — some  of  which 
may  be  very  slight — are  as  follows: 

1.  Chronic  fatigue  of  perception,  memory, 
action,  will,  and  the  nervous  system  generally. 
The  expression  "chronic  fatigue"  may  seem 
inapplicable  to  a  congenital  state,  but  it  has  been 
used  in  preference  to  "weakness"  because  the 
condition  resembles  fatigue  rather  than  simple 
deficiency  in  strength  or  acuity:  it  exhibits  not 
only  this  deficiency  but  also  irritability ;  moreover 
action  takes  an  abnormally  long  time  to  reach  its 
maximum,  and  effort  cannot  be  sustained  regu- 
larly, but  shows  marked  oscillations.  Among  the 
manifestations  of  the  irritable  weakness  just 
referred  to  are  mental  excitability,  and  the  over- 
flowing of  their  habitual  paths  by  impulses,  so  as 
to  give  rise  to  slight  incoordination  of  action,  and 

i  Brit.  Utd.  fourn.,  1903,  Vol.  I,  p.  781.  The  symptoms  from 
infancy  to  adolescence  are  dealt  with  in  this  article. 


TRANSLATOR'S  INTRODUCTION,   xvii. 

occasionally  to  disordered  movements,  especially 
in  children. 

2.  Vasomotor  instability. 

3.  Defective    metabolism.       Professor    Ballet 
calls  attention  (p.  113)  to  the  fact  that  neuras- 
theniform  symptoms  occur  in  auto-intoxications 
and  in  various  diseases  which  are  all,  it  may  be 
observed,    of    a    nature    to    produce    metabolic 
disturbances.    Prof.  Dieulafoy's  "  petits  accidents 
du  brightisme  "  (chronic  nephritis)  are  nearly  all 
symptoms  of  neurasthenia  minor.     The  frequent 
occurrence  in  the  urine  of   signs   of   perverted 
katabolism  (the  features  mentioned  on  pp.  88,  89 
may  be  found  in  the  minor  complaint  as  well  as 
in  the  major)  points  in  the  same  direction  ;  so 
also  does  the  combination,  insisted  on  by  Prof. 
Ballet,  of  neurotic  and  arthritic  manifestations. 

4.  Abnormalities  of  internal  secretions  (prob- 
ably).    These    are    indicated    by    the    likenesses 
between  neurasthenia  and  exophthalmic  goitre ; 
by  the  occasional  occurrence  of  errors  of  develop- 
ment similar  to  those   found  in  persons  whose 
testes  or  ovaries   have   been   removed ;   by  the 
defective    metabolism ;     and  perhaps    also    the 
frequent  tendency  to  alcoholism  points,  as  sug- 
gested by  Dr.  Harry  Campbell,  to  insufficiency  of 
an  internal  secretion  of  a  stimulating  nature. 

5.  Often,  if   not   always,  some   diminution   of 
sexual  power. 

6.  One  or  more  slight  bodily  malformations. 


xviii.  TRANSLATOR'S  INTRODUCTION. 

Now  these  conditions  are  characteristic  of 
"  degenerates,"1  so  that  Neurasthenia  Minor  is 
evidently  a  manifestation  of  Degeneracy.  This 
opinion  is  to  some  extent  corroborated  by  Prof. 
Ballet's  statement  (p.  36)  that  neurasthenia 
"  constitutes  one  of  the  gates  of  entry,  perhaps 
"  the  principal  gate,  into  the  ground  of  pathologi- 
"  cal  heredity."  In  other  words,  according  to  the 
view  here  taken,  it  is  a  manifestation  of  the 
fundamental  condition  (degeneracy)  that  lies  at 
the  base  of  most  neuropathic  states. 

Neurasthenia,  then,  using  the  term  in  the  sense 
in  which  it  is  employed  in  the  present  work 
(neurasthenia  major),  may  be  defined  as  a  group 
of  symptoms  due  to  chronic  fatigue  with  (perhaps 
one  should  rather  say  including)  defective 
metabolism  and  vasomotor  irregularity,  which 
may  be  produced  de  novo  by  cares,  prolonged 
intoxications,  various  drains  upon  the  system, 
certain  strong  emotions,  or  some  forms  of 
trauma,  but  which  results  much  oftener  from 
the  action  of  one  of  these  influences  on  a 
"  degenerate  "  constitution  that  has  shown  some 
degree  of  chronic  fatigue  from  infancy.2 

1  See  Brit.  Med.  Journ.,  1906,  Vol.  I,  p.  494,  and  art.  Degeneracy 
in  Edin.  Med.  Journ.,  1907,  p.  117. 

2  Healthy  persons  do  not  worry  beyond  measure,  and  it  seems 
unlikely  that  mental  stress  alone  can  throw  a  normal  mind  off  its 
balance  in  any  direction.     In  his   Morison  Lectures  of  last  year, 
Dr.    Urquhart  stated   that    all   his   cases  of  insanity  that   were 
ascribed  to  this  cause  showed  a  neuropathic  heredity.     (See  Journ. 
Ment.  Sci.,  Vol.  LI  1 1,  pp.  260,  399.) 


TRANSLATOR'S  INTRODUCTION,   xix. 

This  last  clause  is  in  decided  disagreement 
with  the  statement  on  p.  15  that  the  cases  in 
which  heredity  acts  as  a  predisposing  cause 
amount  to  only  40  per  cent,  of  all  cases.  As 
against  this,  Prof.  Dana,  of  New  York,  holds  that 
there  is  inherited  weakness  of  nerve  structure  in 
the  vast  majority  of  the  patients.1  Apart  from 
certain  objections  to  the  word  "  inherited "  in 
this  connection,  my  experience  goes  to  confirm 
Prof.  Dana's  opinion.  I  have  very  rarely  been 
unable  to  trace  either  a  neurotic  family  history, 
or  a  personal  history  of  neurasthenia  minor,  in 
patients  with  the  major  complaint,  and  anatomi- 
cal stigmata  of  degeneracy  are  very  common. 
Here  it  may  be  pointed  out  that  the  word 
"  neurotic,"  when  it  is  not  applied  to  some 
recognised  and  well-defined  neurosis  or  psychosis, 
always  refers  to  neurasthenia  minor. 

In  what  way  do  worry,  emotion,  and  intoxica- 
tions exacerbate  the  congenital  form  of  neuras- 
thenia, so  as  to  produce  the  major  complaint  ? 
Neurasthenic  symptoms  occur  in  certain  diseases 
in  which  there  have  been  found  products  of 
imperfect  metabolism  (such  as  /3-oxybutyric  acid 
in  diabetes)  which  give  rise  to  phenomena  of 
fatigue  in  a  muscle  that  is  irrigated  with  them.2 
Now  the  condition  of  degeneracy  is  accompanied 
by  faulty  metabolism,  and  this  is  increased  by 

1  Twentieth  Century  Practice  of  Medicine,  Vol.  X,  p.  753, 

2  See  paper  read  at  the  meeting  of  the  Brit.  Med.  Assoc.,  1906, 
by  Prof.  Lee,  New  York. 


xx.     TRANSLATOR'S  INTRODUCTION. 

emotion.  It  is  possible,  then,  that  the  develop- 
ment of  neurasthenia  major  in  a  degenerate  is,  in 
many  instances  at  least,  parallel  to  the  occurrence 
of  neurasthenic  symptoms  in,  say,  diabetes,  and 
that  both  are  due  to  the  presence  of  intoxicating 
products  of  abnormal  metabolism.  Prof.  Clifford 
Allbutt  thinks  that  the  symptoms  of  neurasthenia 
are  too  enduring  to  depend  on  fatigue  products1; 
but  the  long  duration  may  be  due  to  the 
circumstance  that  the  toxins  act  on  nerve  centres 
that  are  already  suffering  from  a  degree  of  chronic 
fatigue,  due  to  the  faulty  metabolism  of  degeneracy. 
The  connection  of  neurasthenia  with  degener- 
acy explains  the  occurrence,  both  in  the  personal 
and  in  the  family  history  of  neurasthenics,  and 
in  their  later  life,  of  other  conditions  that  are 
also  associated  with  degeneracy.  Among  these 
conditions  are  the  various  neuroses  and  psychoses, 
disorders  of  nutrition,  the  arthritic  complaints  on 
which  Prof.  Ballet  lays  stress,  chilblains  and 
"dead"  fingers,  arterio-sclerosis,  Bright's  disease, 
tuberculosis,  and  heart-disease.  The  nature  of 
this  association  belongs  to  the  subject  of 
degeneracy,2  but  reference  may  be  made  here 
to  the  connection  between  neurasthenia  and 
insanity.  It  has  been  said  that  when  a  patient 

i  System  of  Medicine,  Vol.  VIII,  p.  151. 

a  See  Edin.  Med.  Journ.,  loc.  cit.  To  put  it  briefly,  th«  asso- 
ciated conditions  are  due  to  imperfect  development,  to  vasomotor 
irregularities,  to  faulty  metabolism,  which  both  interferes  with 
nutrition  and  gives  rise  to  toxins,  and  perhaps  to  defective  internal 
secretions. 


TRANSLATOR'S  INTRODUCTION,     xxi. 

with  neurasthenic  symptoms  shows  signs  of 
insanity,  the  case  has  been  one  of  insanity  from 
the  beginning.  The  usual  state  of  matters  in 
these  cases  is  that  the  patient  has  suffered  from 
neurasthenia  minor  since  his  birth.  The  exciting 
causes  of  the  insanity  have  aggravated  the 
neurasthenia,  and  so  has  the  morbid  introspec- 
tion that  forms  part  of  certain  kinds  of  insanity ; 
and  further,  the  loss  of  self-control  has  both 
increased  the  neurasthenic  symptoms,  and 
rendered  them  more  manifest.  In  other  cases, 
it  is  true,  these  symptoms  may  be  due  to  the 
disorder  of  metabolism  that  forms  an  integral 
part  of  the  insanity;  but  it  will  be  found  that  a 
large  proportion  of  neurasthenic  insane  patients 
show  anatomical  and  other  stigmata  of  degener- 
acy, and  so  have  probably  been  more  or  less 
neurasthenic  from  birth. 

The  association  of  neurasthenia  and  degeneracy 
may  also  help  to  explain  certain  symptoms  which 
are  often  considered  as  belonging  to  the  former 
condition:  exaggerated  reflexes,  low  blood- 
pressure,  shallow  respiration,  and  sometimes 
attacks  of  migraine.  The  first  two  of  these, 
perhaps  all  of  them,  are  no  doubt  increased  in 
many  cases  of  neurasthenia ;  but  all  four  may  be 
found  in  simple  degeneracy  (neurasthenia  minor), 
and  in  most  cases  of  neurasthenia  major  it  will 
be  found  that  they  were  present  before  the 
attack  began. 


xxii.    TRANSLATOR'S  INTRODUCTION. 

Again,  the  connection  between  neurasthenia 
and  degeneracy  explains  the  mistaken  diagnoses 
dealt  with  in  Part  III,  ch.  5.  The  diseases 
confounded  with  neurasthenia  major  are,  like  it, 
founded  on  a  basis  of  neurasthenia  minor,  and  so 
display  the  "  neurastheniform "  symptoms  of 
which  Prof.  Ballet  speaks. 

It  also  explains  the  relation,  mentioned  on  p. 
124,  between  the  neurosis  of  anxiety  and 
neurasthenia. 

Finally,  it  affords  an  explanation  of  the  connec- 
tion between  neurasthenia  and  enteroptosis, 
which  seems  to  me  more  satisfactory  than  either 
that  of  Glenard  (p.  283)  or  that  of  Bouveret  (p. 
284),  and  which,  unlike  the  theories  of  these 
observers,  serves  also  to  explain  why  such 
conditions  as  mobile  heart,  uterine  displace- 
ments (in  nulliparae),  spinal  curvature,  flat- 
foot,  varicocele  and  perhaps  genu  valgum,  are 
more  common  in  neurasthenics  than  in  normal 
subjects.  Among  the  fairly  common  signs  of 
degeneracy  are  want  of  muscular  tone  and 
hyperplasia  of  connective  tissue,  resulting  in 
laxity  of  attachments ;  two  conditions  which 
suffice  to  account  for  enteroptosis  and  the  other 
pathological  states  just  mentioned.1 

In  this  connection,  it  is  interesting  to  observe 
that  Prof.  Ballet  makes  a  distinction  between 

i  See  article  on  Neurasthenia,  Degeneracy,  and  Mobile  Organs,  by 
the  translator,  in  Brit.  Med.  Journ.,  March  3rd,  1906. 


TRANSLATOR'S  INTRODUCTION,   xxiii. 

Hypochondriasis  Major  and  Hypochondriasis 
Minor,  and  associates  the  latter  with  neuras- 
thenia. It  would  seem,  in  fact,  that  hypochondri- 
asis,  as  well  as  the  maladie  du  doute,  is 
essentially  a  neurasthenic  symptom,  and  that 
minor  degrees  of  the  three  conditions  are  found 
in  nearly  all  cases  of  degeneracy,  and  are  all 
combined  together — in  varying  proportions — in 
those  persons  who  are  liable  to  develop  the 
major  degree  of  any  one  of  them. 

None  the  less,  one  must  follow  Prof.  Ballet  in 
insisting  most  strongly  on  the  fact  that  the 
course,  prognosis,  and  treatment  of  neurasthenia 
(major)  are  totally  different  from  those  of  the 
other  diseases  that,  like  it,  flourish  on  a  soil  of 
degeneracy.  These  diseases  must,  as  he  says, 
be  carefully  differentiated.  It  will  probably  be 
found  that  a  recognition  of  the  relationship 
between  neurasthenia  and  degeneracy,  so  far 
from  causing  confusion,  will  aid  considerably  in 
making  such  differentiation ;  it  will  enable  the 
symptoms  of  neurasthenia  minor  to  be  recognised 
and  put  aside,  so  that  the  diagnosis  may  be  based 
on  the  superadded  features.  A  patient  who 
complains  of  languor,  especially  on  waking  in  the 
morning,  of  speedy  exhaustion,  of  inability  to  fix 
the  mind,  and  perhaps  of  dull  pains,  will  not 
have  his  complaint  hastily  diagnosed  as  one  of 
neurasthenia  (major),  if  it  be  recognised  that 
these  are  symptoms  of  the  minor  affection, 


xxiv.  TRANSLATOR'S  INTRODUCTION. 

perhaps  somewhat  exacerbated,  and  are  common 
to  a  whole  group  of  maladies. 

In  his  recent  remarkable  work,  "The  Dissocia- 
"  tion  of  a  Personality,"  Dr.  Morton  Prince  holds 
that  neurasthenic  symptoms  are  a  manifestation 
of  disintegration  of  the  personality.  This,  how- 
ever, appears  to  refer  to  neurasthenia  accompa- 
nied by  hysteria.  The  combination  of  these  two 
conditions  points  almost  certainly  to  degeneracy, 
a  view  which  is  supported  by  the  fact  that  Dr. 
Prince's  patient,  when  reintegrated  and  freed 
from  the  symptoms  of  neurasthenia  major,  seems 
to  have  retained  those  of  neurasthenia  minor. 
The  case,  however,  raises  other  difficulties.  It 
was  one  of  multiple  personality,  and  one  of  the 
personalities  was  markedly  neurasthenic,  while 
another  appeared  very  vigorous,  even  symptoms 
of  neurasthenia  minor  seeming  to  be  totally 
absent.  This  would  apparently  indicate  that 
neurasthenia  minor  is  purely  functional,  and  has 
no  organic  basis  such  as  we  hold  to  exist  in 
degeneracy,  and  as  Prof.  Ballet  also  believes  to 
exist  in  neurasthenia.  Moreover,  the  change 
from  the  feeble  to  the  vigorous  personality  was 
accompanied  by  an  immediate  disappearance  of 
the  neurasthenic  symptoms — too  sudden,  one 
might  think,  to  be  compatible  with  the  dependence 
of  those  symptoms  on  a  toxic  influence.  But  it 
is  hazardous,  in  the  present  state  of  our  know- 
ledge, to  draw  inferences  from  cases  of  this 


TRANSLATOR'S  INTRODUCTION,    xxv. 

class.  Neurasthenics  feel  buoyant  and  energetic 
occasionally,  and  it  may  be  that  the  conditions 
which  brought  about  such  a  feeling  in  the  case 
referred  to,  caused  also  the  appearance  of  the 
vigorous  personality ;  and  that  with  their 
disappearance  the  vigorous  personality  gave 
place  to  the  feebler.  Moreover  it  is  highly 
probable  that  the  apparent  vigour  was  really  due, 
not  to  healthy  nerve  centres,  but  to  that  disorder 
of  common  sensation  which  consists  in  a  loss  of 
the  sense  of  fatigue.  Dr.  Prince's  promised 
second  volume  will,  we  hope,  throw  light  on  this 
and  many  kindred  questions. 

As  regards  the  treatment  of  neurasthenia,  all 
must  agree  with  Prof.  Ballet's  condemnation  of 
the  routine  use  of  drugs.  Nevertheless,  medi- 
cinal treatment  of  symptoms  is,  as  he  shows, 
required  at  times ;  for  in  no  complaint  does  it 
happen  more  frequently  that  the  patient  gets  into 
a  vicious  circle,  the  fundamental  disorder  pro- 
ducing symptoms  which  again  maintain  and 
aggravate  the  disease.  Among  such  symptoms, 
or  secondary  affections,  are  constipation,  dyspep- 
sia, and  auto-intoxications,  the  treatment  of 
which,  by  drugs  and  otherwise,  is  fully  and  clearly 
dealt  with  in  this  work;  also  insomnia,  for  which, 
however,  the  methods  of  treatment  here  given 
are  far  superior  to  medicaments ;  and  nerve- 
storms  like  migraine  and  "  bilious  attacks,"  which 
exacerbate  neurasthenia  almost  as  much  as  does 


xxvi.    TRANSLATOR'S   INTRODUCTION. 

insomnia,  and  in  which  calomel  acts  like  a  charm, 
relieving  both  the  asthenia  and  the  nerve-storm. 
Dr.  Guthrie  Rankin  recommends  the  treatment 
of  marked  vasomotor  instability  by  5  or  10  grain 
doses  of  ichthyol.  Far  more  important  than 
drugs,  however,  are  removal  from  home  (except 
in  mild  cases  of  pure  cerebrasthenia),  a  medi- 
cal attendant  who  inspires  confidence  and  courage, 
and  various  measures  of  physical  hygiene.  Among 
these  last  is  one  on  which  perhaps  too  little  stress 
has  hitherto  been  laid :  the  open-air  treatment. 
The  value  of  this  in  neurasthenia  is  often  very 
great,  and  it  should  be  carried  out  as  thoroughly 
as  in  phthisis.  This,  of  course  can  best  be  done 
in  special  establishments ;  failing  these,  windows 
should  be  kept  open  as  widely  as  possible,  both 
day  and  night,  curtains  should  be  abolished,  and 
blinds  should  be  drawn  up  even  at  night.  Even 
insomnia  is  not  always  a  centra-indication  to  the 
disuse  of  blinds. 

Of  late  it  has  been  maintained — by  Dr.  Dubois 
in  Switzerland,1  Drs.  Dejerine,  Camus  and  Pagniez 
in  France,1  and  Dr.  Drummond  in  this  country2 — 
that  the  essential  part  of  the  treatment  of 
neurasthenia  is  mental,  consisting  of  an  appeal  to 
the  patient's  reason.  This  view  seems  to  be 
founded  on  a  misconception  of  the  pathogeny  of 
the  disease.  It  is  true  that  such  an  appeal  is 

i  See  pp.  178  seqq.  of  this  work. 

a  Brit.  Med.Journ.,  1907,  Vol.  II,  p.  1813. 


TRANSLATOR'S  INTRODUCTION,  xxvii. 

always  valuable— see  pp.  181,  196,  and  200  to  207 
of  this  work — and  in  mild  cases  it  may  be  made 
from  the  outset ;  but,  surely,  one  of  the  earliest 
practical  lessons  that  one  learns  in  treating  cases 
of  the  psychoses  of  any  degree  of  severity, 
whether  there  be  intellectual  derangement  or  not, 
is  the  futility  of  appealing  to  the  "  higher  mental 
levels "  before  the  general  condition  has  con- 
siderably improved.  This,  indeed,  follows  from 
the  pathogeny  of  the  complaints.  The  question 
is  discussed  in  Part  VI,  ch.  2,  of  the  present 
work,  which  gives  an  admirable  account  of  the 
psychical  treatment  of  neurasthenia,  in  all  its 
branches.  One  additional  point,  however,  a  point 
of  value  in  many  cases,  is  well  brought  out  by  Dr. 
Drummond:  he  shows  that  it  is  necessary  not 
only  to  cheer  and  reassure  the  patient,  but  also  to 
stimulate  hkn  to  depart  from  his  self-involvement, 
to  widen  his  interests  and  sympathies,  and  to 
strengthen  his  sense  of  duty.  It  must  be  remem- 
bered, however,  that  this  applies  to  cases  with  a 
strong  element  of  hypochondriasis ;  it  would  be 
incorrect  and  unjust  to  suppose  that  every 
neurasthenic  is  selfish  and  self-centred. 

The  author  seems  to  have  been  unfortunate  in 
his  experience  of  boarding-schools  in  his  native 
land.  Fortunately  for  us,  things  are  better  in  that 
respect  in  England,  though  in  many  schools  the 
hours  of  sleep  are  still  too  short.  The  question 
whether  a  neurotic  boy  should  go  to  a  boarding- 


xxviii.  TRANSLATOR'S  INTRODUCTION. 

school  or  a  day-school  must  be  decided  by  the 
individual  circumstances  of  the  case,  including 
the  character  of  the  child's  parents. 

In  translating  this  work,  I  have  converted 
metric  weights  and  measures  into  their  English 
equivalents,  either  exactly,  or  omitting  fractions, 
or  using  the  nearest  round  number,  according  to 
the  degree  of  precision  required.  The  use  of 
English  weights  has  necessitated  the  making  of 
new  blocks  for  Figures  4  to  7,  for  which  I  have  to 
thank  the  Publisher.  In  other  respects  I  have 
tried  to  be  as  literal  as  the  differences  between 
the  two  languages  will  permit,  holding  accuracy 
of  interpretation  to  be  the  most  important  quality 
in  the  translation  of  a  scientific  work.  I  wish 
that  I  could  have  preserved  more  fully  the  clear- 
ness of  expression  that  is  so  marked  a  feature  of 
the  original. 


PART  I. 

DEFINITION  AND  NATURE  OF  NEURAS- 
THENIA. 

Neurasthenia  is  a  neurosis,  that  is  to  say  a  disease 
of  the  nervous  system  without  known  organic 
lesion,  which  Beard  of  New  York  had  the  merit  of 
disentangling  from  the  chaos  of  the  old  vague 
group  of  complaints  known  as  "  nervous." 

It  manifests  itself  by  functional  derangements 
which  are  very  many  in  number,  very  diversely 
associated,  and  for  the  most  part  subjective  in 
nature.  We  possess  no  certain  data  as  to  the 
modifications  of  the  nerve  centres  from  which 
these  functional  derangements  spring ;  we  know 
only  their  clinical  appearance  and  their  causes, 
and  it  is  solely  from  an  induction  founded  on  the 
characters  of  these  that  we  can  conjecture  the 
nature  of  the  affection.  As  it  often  originates  in 
over-pressure  of  the  higher  nerve  centres,  and  as  it 
shows  itself  chiefly  by  signs  of  depression,  of  weak- 
ness of  nerve  strength,  it  is  supposed  that  we  are 
here  concerned  with  an  intimate  derangement  of  the 
nutrition  of  the  nerve  elements  ;  these  elements, 
it  is  thought,  have  increased  difficulty  in  recruiting 

Neurasthenia  1 


2  NEURASTHENIA. 

their  exhausted  energy,  and  no  longer  accumulate 
to  the  same  degree  as  in  health  the  force  that 
they  discharge ;  thus  this  neurosis  is  commonly 
defined  as  chronic  enfeeblement  of  nerve  strength. 
Hence  also  it  is  frequently  called  nervous  exhaus- 
tion, or  nervous  weakness.  But  as  symptoms  of 
excitement  are  frequently  seen  associated  with 
the  signs  of  depression,  neurasthenia  is  sometimes 
more  accurately  and  fully  designated  as  irritable 
weakness. 

This  irritable  weakness  may  manifest  its  effects 
not  only  on  the  side  of  the  cerebro-spinal  system, 
but  also  on  the  side  of  the  nerves  of  organic 
life.  Neurasthenia  not  only  disturbs  the  highest 
and  best  differentiated  functions,  those  of  the 
brain  and  the  spinal  cord,  but  also  affects  almost 
always,  though  in  varying  degrees,  the  innervation 
of  the  principal  viscera.  Three  great  systems  in 
especial  suffer,  the  circulatory,  digestive,  and 
genito-urinary.  Hence  it  is  easy  to  understand 
how  great  is  the  diversity  of  the  functional  dis- 
orders observed  in  neurasthenics.  As  the  symp- 
toms may  be  grouped  very  differently  in  different 
patients,  it  follows  that  the  complaint  presents 
itself  clinically  in  many  and  varied  forms.  And  yet, 
whatever  be  the  multiplicity  of  the  groups  of 
symptoms  and  of  the  causes  that  engender  them, 
there  are  relations  and  similarities  of  character 
between  all  these  states  of  nervous  debility  that 
establish  beyond  doubt  the  independence  of  the 


DEFINITION  AND  NATURE.  3 

neurosis.  The  fundamental  symptoms  of  this 
affection  are  several  in  number :  a  persistent 
headache  of  a  special  character,  insomnia,  muscu- 
lar asthenia,  rachialgia,  a  peculiar  mental  state, 
and  lastly  dyspepsia  due  to  gastro-intestinal  atony. 
These  cardinal  signs,  united  in  greater  or  smaller 
number,  characterise  the  nervous  condition  des- 
cribed by  Beard,  a  condition  which  cannot  be  con- 
founded with  any  other  aggregate  of  neuropathic 
symptoms. 

The  fixity  of  the  symptomatology,  or  at  least  of 
its  essential  features,  establishes  a  fundamental 
distinction  between  neurasthenia,  an  exhaustion 
disease,  manifesting  itself  by  symptoms  of  exhaus- 
tion, and  the  neuroses,  particularly  hysteria,  in 
which  the  disorders  are  more  especially  psychic 
in  nature,  and  depend  on  the  fixation  in  the  mind 
of  certain  images,  or,  in  the  current  phrase,  of 
suggestions.  We  shall  show  that  neurasthenia  is 
a  somatic  disease  of  the  nervous  system,  and  may 
be  contrasted  with  hysteria,  which  is  a  psychical  dis- 
ease, and  variable  in  its  manifestations  as  psychical 
diseases  are.  There  are,  however,  many  and 
close  relations  between  mental  processes  and  neur- 
asthenia: on  the  one  hand,  mental  processes  may 
cause  neurasthenia,  as  when  the  latter  arises  from 
emotions  or  disappointment ;  and  on  the  other 
hand,  the  state  of  exhaustion  which  constitutes 
the  disease  brings  about  conditions  that  are 
favourable  to  the  development  of  a  pathological 


4  NEURASTHENIA. 

mental  state  (melancholy,  aboulia,  phobias,  auto- 
suggestions), the  type  of  which  is  the  association 
of  hysteria  with  neurasthenia — hystero-neuras- 
thenia.  But  even  in  those  cases  in  which  neuras- 
thenia is  complicated  by  secondary  and  associated 
disorders,  it  retains  its  fundamental  and  essential 
character  of  an  exhaustion  disease. 

This  view,  according  to  which  the  totality  of  the 
disorders  that  make  up  the  affection  is  due,  at 
any  rate  on  final  analysis,  to  a  special  state  of 
weakness  and  irritability  of  the  nerve  elements, 
has  not  been  accepted  by  all  clinical  observers  ;  it 
has  been  sought  to  make  the  different  symptoms 
of  the  malady  depend  on  certain  visceral  derange- 
ments. Thus  some  have  tried  to  recognise  disorder 
of  the  digestive  functions  as  the  origin  of  the  neu- 
ropathic state,  and  have  thought  that  dyspepsia,  by 
the  perturbation  of  nutrition  that  it  causes,  may 
be  the  primary  and  fundamental  cause  of  the  ner- 
vous exhaustion.  Others  have  incriminated  lesions 
of  the  genito-urinary  system  and  genital  excesses. 
Finally,  it  has  been  held  that  the  weakness  of  the 
nervous  centres  may  be  the  consequence  of  a  state 
of  poverty  of  the  blood,  as  if  nervous  asthenia 
were  necessarily  associated  with  anaemia.  We 
shall  have  to  discuss  later  these  diverse  theories 
which  aim  at  elucidating  the  still  obscure  patho- 
geny  of  the  neurosis ;  we  shall  then  see  how 
much  truth  they  may  contain.  But  we  may  say 
at  once  that  in  the  majority  of  cases  these  patho- 


DEFINITION  AND  NATURE.  5 

genie  theories  are  contradicted  by  direct  observa- 
tion of  cases.  It  seems  certain  that  gastro-intes- 
tinal  atony  and  genito-urinary  derangements  are 
more  often  the  effect  than  the  cause  of  the  affec- 
tion. As  to  anaemia,  neurasthenia  is  assuredly  in- 
dependent of  it ;  how  many  neurasthenics  there 
are  with  a  good  complexion,  normal  blood,  and  all 
the  external  signs  of  flourishing  health  !  In  fact 
all  the  functional  disturbances  observed  in  these 
patients  appear  to  depend  on  the  primordial  alter- 
ation of  the  nerve  elements,  of  which  it  is  true  the 
intimate  nature  escapes  us.  The  study  of  the  vari- 
ous causes  of  the  disease,  moreover,  will  enable  us 
to  show  clearly  the  preponderating  r6le  in  the 
pathogeny  of  neurasthenic  states  played  by  the 
direct  and  primary  affection  of  the  nervous  centres. 
However  this  be,  neurasthenia  cannot  at  the 
present  moment  be  defined  by  its  pathogenic 
origin,  our  conception  of  which  is  vague ;  nor  by  its 
lesions,  since  it  presents  none  appreciable  by  our 
means  of  investigation  ;  nor  by  its  pathological 
physiology,  which  is  still  very  obscure.  We  are 
necessarily  led  then  to  seek  in  the  study  of  its 
etiology  and  clinical  characters  the  rational  indi- 
cation of  the  hygienic  measures  to  be  employed  in 
its  prophylaxis  and  treatment. 


PART  II. 

THE  CAUSES  OF  NEURASTHENIA:  WHY  AND 
HOW  ONE  BECOMES  NEURASTHENIC, 

CHAPTER  I. 
GENERAL  CAUSES, 

Neurasthenia  is  not,  as  Beard  believed,  a  modern 
disease  created  by  the  intellectual  and  moral  over- 
pressure inherent  in  civilisation  and  in  the  social 
life  of  our  epoch.  It  is  probable  that  it  has  existed 
in  all  times,  like  the  other  neuroses  and  psychoses 
to  which  depressing  emotions  and  moral  and 
physical  shocks  may  give  rise  in  man.  It  is  cer- 
tain in  any  case  that  the  physicians  of  past  cen- 
turies observed  it,  notably  Galen,  Stoll,  Syden- 
ham,  and  Robert  Whytt  (as  is  proved  by  many 
passages  of  their  writings),  although  they  could 
not  disengage  it  from  the  other  neuropathic  states 
with  which  it  long  remained  confounded.  But  it 
is  none  the  less  true  that  at  the  present  day  neur- 
asthenia is  a  very  common  disease,  and  it  even 
seems,  as  the  majority  of  modern  authors  agree  in 
recognising,  that  it  tends  to  grow  more  and  more 
frequent.  It  is  not  without  reason  that  it  has  been 


GENERAL  CAUSES.  7 

called  "  the  disease  of  the  century."  And  indeed 
this  appellation  seems  to  be  justly  applicable  to  it 
if  it  be  understood  thereby  not  that  neurasthenia 
has  appeared  in  our  epoch  as  a  newly-formed 
morbid  species,  but  that  it  has  taken  in  our  time 
a  development  that  perhaps  it  never  attained  be- 
fore. This  would  be,  if  it  were  proved,  a  remark- 
able fact  in  the  natural  history  of  the  neurosis.  It 
is  not  without  interest,  for  the  hygienist  at  least, 
to  seek  for  its  causes. 

If  our  epoch  is,  as  has  been  said,  particularly 
fertile  in  neurasthenics,  is  it  true  that,  as  some 
have  suggested,  it  owes  this  unhappy  privilege  to 
a  sort  of  all-round  degeneration  which,  following 
a  law  of  regressive  evolution,  has  invaded  the  late- 
come  generations,  the  issue  of  peoples  grown  old  or 
of  worn-out  races  ?  Such  an  interpretation  seems 
to  us  disputable,  like  the  pessimistic  judgment 
that  certain  authors  have  delivered,  rather  lightly, 
on  the  present  generation.  To  convince  oneself 
of  this,  it  is  enough  to  glance  at  the  ethnographic 
distribution  of  neurasthenia.  Certainly  it  is  spread 
over  France,  Germany,  Russia,  all  the  peoples  of 
old  Europe ;  but  its  frequency  is  not  less  in 
America ;  it  is  even  especially  common  there,  so 
much  so,  that  Beard  (of  New  York),  when  he  des- 
cribed it,  thought  he  had  discovered  a  morbid 
species  peculiar  to  the  country  where  he  observed 
it,  in  one  word,  according  to  his  own  expression, 
"  an  American  disease."  If  neurasthenia  has  taken 


8  NEURASTHENIA. 

a  considerable  extension  in  the  United  States,  a 
young  country  of  recent  civilisation  and  peopled 
by  a  strong  race,  there  is  no  ground  for  asserting 
that  the  development  of  this  neurosis  is  to  be  im- 
puted especially  to  a  sort  of  senility  or  regressive 
evolution  on  the  part  of  the  nations  it  attacks. 
Besides,  are  we  justified  in  holding  that  the  peoples 
of  Europe  among  which  this  affection  is  common- 
ly observed,  are  on  the  road  to  physical  and 
psychical  decay  ?  Is  it  true  that  the  French  and 
the  Germans  of  our  time  are  feebler  than  those 
who  lived  in  the  last  century  or  even  in  the  Middle 
Ages  ?  One  may  at  least  doubt  this,  if  one  thinks 
of  the  enormous  burdens  supported  by  the  nations 
of  contemporary  Europe,  and  of  the  immense 
labour'that  they  accomplish  in  all  spheres  of  human 
activity.  In  reality  neurasthenia  is  equally  spread 
amongst  all  civilised  peoples,  in  whom  the  struggle 
for  existence  keeps  up  an  incessant  and  exagger- 
ated exaltation  of  the  functions  of  the  nervous 
system.  Hence  it  is  extremely  frequent  among 
Americans,  whose  extraordinary  activity  is  well 
known,  and  among  the  nations  of  Europe  that 
lead  the  van  of  civilisation.  If  it  became  par- 
ticularly common  in  the  course  and  at  the  end  of 
the  nineteenth  century,  that  is  because  the  con- 
ditions of  social  life  were  abruptly  modified,  both 
economically  and  politically. 

Formerly   the   different   social   classes    were 
penned,  as  it  were,  behind  impassable  barriers, 


GENERAL  CAUSES.  9 

and  very  few  except  the  strong  sought  to  leave  the 
surroundings  in  which  the  chance  of  birth  had 
placed  them.  To-day,  laws  and  customs  have 
abolished  those  barriers  ;  everyone  endeavours  to 
raise  himself  higher  than  his  ancestors ;  compe- 
tition has  increased  ;  conflicts  of  interests  and  of 
persons  have  multiplied  in  all  conditions  of  life  ; 
free  course  is  given  to  ambitions  that  are  often 
little  justified  ;  a  crowd  of  individuals  impose  on 
their  brains  a  work  beyond  their  strength ;  then 
come  cares  and  reverses  of  fortune,  and  the  ner- 
vous system,  under  the  wear  and  tear  of  incessant 
excitation,  at  last  becomes  exhausted.  Thus  may 
be  explained  the  increasing  frequence  of  neuras- 
thenia in  our  time,  and  its  predominance  in  towns, 
among  the  middle  and  upper  classes,  in  a  word  in 
all  circumstances  where  intellectual  culture  or 
commercial  and  industrial  traffic  are  carried  to 
their  highest  degree  of  intensity. 

These  considerations  enable  us  already  to  foresee 
that  over-pressure,  and  especially  cerebral  over- 
pressure, must  figure  in  the  front  rank  of  the  causes 
of  neurasthenia. 

Age, — The  disease  is  not  equally  frequent  at  all 
ages.  Very  rare  in  childhood  and  old  age,  it  affects 
adults  by  preference,  that  is  to  say  it  attacks  man 
in  the  most  laborious  and  most  harassed  period  of 
his  existence,  from  his  twentieth  to  his  fiftieth 
year. 

There  is  however  one  form  of  neurasthenia  that 


10  NEURASTHENIA. 

may  be  described  as  precocious  neurasthenia,  and 
that  we  have  often  observed.  It  makes  its  appear- 
ance about  puberty  or  a  little  later,  and  seems  to 
be  connected  with  an  exaggerated  growth  in  height. 
It  is  found  in  patients  who  are  notably  taller  than 
the  average,  and  whose  girth  of  chest  and  volume 
of  muscles  are  not  proportionate  to  their  height. 
These  neurasthenics  almost  always  belong  to  the 
male  sex.  They  are  "  long  lean  "  persons,  whose 
nervous  system  is  endowed  with  excessive  fragility 
and  yields  to  the  slightest  shock. 

Sex. — Neurasthenia  is  commoner  among  men 
than  among  women.  Out  of  a  total  of  828  patients, 
von  Hossling1  counted  604  cases  in  the  male  sex, 
and  only  224  in  the  female  sex.  This  unequal 
division  of  the  disease  between  the  sexes  cannot 
be  explained  by  a  special  predisposition  on  the 
part  of  the  male  sex.  Here  again  appears  the 
preponderating  influence  of  stubborn  labour,  of 
cares,  and  of  excesses  of  all  sorts,  consequences 
of  the  more  active  and  more  militant  part  played 
by  man  in  the  struggle  for  existence. 

Profession. — The  distribution  of  the  cases  among 
the  professions  is  no  less  significant.  The  statis- 
tics that  have  been  drawn  up  from  this  point  of 
view  show  clearly  the  predominating  influence  of 
cerebral  over-pressure  in  the  development  of 
neurasthenia.  Among  598  patients  were  found  :2 

iVon   Hossling,  in   Handbuch  der  Neurasthenic,  herausgeg.     von 
Franz  Miiller,  Leipzig,  1893. 
3Von  Hossling,  loc.  cit. 


GENERAL  CAUSES.  11 

Merchants  and  manufacturers  -     198 
Clerks  -     130 

Professors  and  teachers  68 

Students  -  -       56 

Officers    -  -       38 

Artists      -  -       33 

Without  profession  -         -  19 

Medical  men     -  17 

Agriculturists    -  -       17 

Clergy  10 

Men  of  science  and  learning     -         6 
Schoolboys  6 

Working  men    -  6l 

Although  they  have  merely  a  quite  relative  value, 
these  figures  are  none  the  less  instructive.  They 
show  the  extreme  rarity  of  the  neurosis  among  the 
labouring  class,  and  its  almost  exclusive  limitation 
to  the  cultivated  classes,  to  the  world  of  affairs, 
and  to  the  liberal  professions,  in  a  word,  to  the 
social  categories  whose  circumstances  involve 
them  in  habitual  brain-work.2 

rThese  figures,  added  together,  make  604. — Trans. 

2Petren  maintains  that  in  Sweden  neurasthenia  is  commoner 
among  the  artisans  and  peasants  than  among  those  more  highly 
placed  socially ;  and  that  the  rush  of  modern  life  is  certainly  not 
the  chief  exciting  cause,  for  the  majority  of  cases  come  from  pro- 
vincial parts  of  Sweden,  where  life  is  simple  and  tranquil.  (See 
British  Medical  Journal,  1901,  Vol.  II.,  p.  736).  Prof.  Clifford  Allbutt 
has  found  in  England  that  "  neurasthenia  is  found  no  more  in  the 
"  market-place  than  in  the  rectory  or  in  the  workhouse  ;  no  more  in 
"busy  citizens  than  in  idle  damsels;  development  of  the  higher 
"  nervous  centres  makes  for  control,  while,  on  the  other  hand,  list- 
"  lessness,  frivolity,  and  adversity  are  not  confined  to  any  one  rank 
"of  life."  (Art.  Neurasthenia  in  his  System  of  Medicine,  Vol.  VIII., 
p.  135).  See  also  pp.  25 — 28  of  this  work. — Trans. 


CHAPTER  II. 

SPECIAL  CAUSES. 

HEREDITY  AND  EDUCATION. 

Heredity. — The  great  part  played  by  heredity  in 
the  development  of  diseases  of  the  nervous  system 
is  well-known.  But  this  etiological  factor  does 
not  intervene  in  a  uniform  fashion  in  the  patho- 
geny  of  all  nervous  maladies.  Some  neuroses 
seem  more  subject  than  others  to  its  influence, 
and  in  any  one  neurosis  its  action  is  exerted  in 
very  varying  degrees  in  different  cases. 

It  sometimes  happens,  as  is  well-known,  that 
the  same  type  of  disease  is  transmitted  from  one 
generation  to  the  generations  following.  It  is  then 
said  that  there  is  similar  heredity ;  in  such  a  case 
the  hereditary  origin  of  the  malady  is  quite  clear. 
But  it  is  rarely  that  pathological  heredity  shows 
itself  in  so  plain  a  form ;  and  so  far  as  neurasthenia 
is  concerned,  we  may  affirm  that  examples  of 
similar  heredity  are  exceptional. 

In  a  large  number  of  cases  on  the  other  hand, 
nervous  defects  are  found  among  the  ancestors, 
the  influence  of  which  on  the  descendants  is  not 


SPECIAL  CAUSES.  13 

doubtful,  but  which  have  changed  their  form  in 
the  process  of  transmission  ;  we  have  then  dis- 
similar heredity.  These  are  well-known  facts. 
Finally,  it  often  happens  that  in  the  line  of  ances- 
tors of  patients  affected  with  various  psychoses 
or  neuroses,  one  can  discern,  associated  or  not 
with  neuropathic  conditions,  or  alternating  with 
them,  derangements  or  diseases  dependent  on  the 
arthritic  diathesis,  as  gout,  gravel,  or  diabetes. 
This  again  is  a  fact  of  current  observation,  and 
nothing  is  better  established  than  the  reality  of 
this  dissimilar  heredity.  Thus  it  is  admitted  that 
nervous  diseases,  properly  so-called,  and  diseases 
of  arthritic  nature  are  liable  to  give  rise  to  one 
another  in  passing  from  one  generation  to  those  that 
follow.  We  see,  then,  that  neuro-arthritic  heredity 
may  manifest  itself  according  to  very  different 
modes  of  transmission,  and,  we  must  add,  with 
very  variable  intensity.  Sometimes,  indeed,  morbid 
heredity  alone  suffices  to  give  rise  to  this  or  that 
nervous  affection,  but  sometimes — and  this  is  the 
commonest  case — it  seems  to  act  only  as  a  pre- 
disposing cause  and  needs  to  be  seconded  by  ex- 
citing or  accidental  causes.  These  general  prin- 
ciples are  commonplace  notions  to-day  ;  they  com- 
prise almost  all  the  relations  between  heredity 
and  nervous  diseases  so  far  as  they  are  known  at 
present.  It  is  unnecessary  to  add  that  they  are  of 
immense  practical  interest.  Hence  it  is  important 
that  they  be  always  present  to  the  mind  of  the 


14  NEURASTHENIA. 

physician,  whether  his  object  be  to  avert  the 
effects  of  a  threatening  heredity  by  prophylactic 
measures,  or  to  determine — sometimes  a  difficult 
problem — the  shares  respectively  due  to  accidental 
causes  and  to  transmitted  lesions  in  the  frequently 
complex  etiology  of  a  declared  disease.  We  have 
then  to  ask  ourselves  here  what  is  the  precise 
role  of  neuro-arthitic  heredity  in  the  development 
of  neurasthenia.  In  this  connection  we  may 
arrange  the  cases,  in  spite  of  their  great  diversity, 
in  three  groups: 

(a)  There  are  cases  in  which  the  heredity  acts 
alone  and  suffices  to  excite  the  development  of 
the  neurosis.  Certain  subjects  sprung  from  tainted 
families  are  continually  on  the  verge  of  neuras- 
thenia from  their  birth ;  their  nervous  system 
tires,  even  in  the  course  of  a  regular  and  quiet  life, 
and  they  are,  so  to  speak,  inevitably  destined  to 
become  the  prey  of  the  neurosis. 

This  hereditary  form  of  nervous  exhaustion, 
arising  apart  from  the  common  causes  of  the  dis- 
ease, is  indeed  rare,  but  it  is  interesting  to  know. 
For  it  presents  a  somewhat  special  evolution  :  it 
is  usually  precocious  ;  it  manifests  itself  habitu- 
ally at  the  epoch  of  puberty,  sometimes  even 
earlier,  and  it  is  peculiarly  tenacious;  consequently 
it  is  important  to  recognise  it  on  the  first  signs  of 
its  onset,  for  only  at  its  initial  period  can  its  de- 
velopment be  hindered  by  submitting  the  young 
patients  to  appropriate  hygienic  rules. 


SPECIAL  CAUSES.  15 

(b)  In  the  majority  of  cases  neuro-arthritic 
heredity  intervenes  only  as  a  predisposing  cause. 
It  prepares  the  soil  on  which  some  slight  or  severe 
accidental  cause  will  make  neurasthenia  spring 
forth.  The  cases  belonging  to  this  category  are 
many  ;  the  proportion  of  neurasthenics  in  whose 
antecedents  one  finds  hereditary  taints  more  or  less 
marked,  may  be  estimated  at  40  per  cent.  In  this 
connection  we  may  remark  that  the  hereditary 
antecedents  of  neurasthenics  are  in  general  less 
heavily  laden  than  those  of  patients  affected  with 
psychoses,  serious  neuroses,  or  even  organic  dis- 
eases of  the  nervous  system.  Epilepsy,  hysteria,  and 
insanity  rarely  figure  in  the  genealogy  of  neuras- 
thenics ;  and  very  often  we  find  nothing  more  than 
emotional  or  hypochondriacal  tendencies,  hemi- 
crania,  or  irritable  temper  in  their  family  histories. 
It  would  seem,  then,  that  among  the  diseases  of 
the  nervous  system  neurasthenia  is  one  of  those 
least  dependent  on  heredity,  and  that  in  the  greater 
number  of  cases  the  influence  of  this  etiological 
factor  is  inferior  to  that  of  exciting  or  occasioning 
causes.  Here  we  may  recall  the  fact  that  neuro- 
arthritic  heredity  is  not  the  only  possible  predis- 
posing cause  of  neurasthenia.  Others  are  infec- 
tious or  toxic  diseases  existing  in  the  parents  at 
the  moment  of  conception,  or  in  the  mother  during 
pregnancy.  Thus  syphilis  (Kowalewsky),1  tuber- 

iKowalewsky,  Centralblatt  fiir  Ncrvenhcilkunde  und  Psychiatrie, 
1893. 


16  NEURASTHENIA. 

culosis,  malaria,  alcoholism,  lead  poisoning  in  the 
parents  have  been  justly  incriminated  in  a  certain 
number  of  cases.1 

Education. — By  the  side  of  hereditary-  influ- 
ences we  must  notice  another  predisposing  cause 
of  the  first  rank :  defective  education.  The  vicious 
methods  of  education  that  give  rise  to,  or  allow 
the  development  of,  evil  tendencies  and  irregulari- 
ties of  character  in  children,  may,  as  can  easily 
be  imagined,  exert  a  baneful  influence  on  their 
physical  and  moral  energy.  Too  often,  through 
the  carelessness  of  parents  or  masters,  the  child, 
instead  of  starting  life  endowed  with  a  firm  will 
and  enlightened  judgment,  has  become  a  capricious 
and  obstinate  being,  devoid  of  strength  of  will  and 
moral  firmness.  When  to  these  faults  are  further 
added  badly  regulated  instruction  and  an  in- 
sufficient physical  education,  or  even  none  at  all, 
the  subject  is,  so  to  speak,  doomed  inevitably  to 
give  way  before  every  difficulty  in  the  struggle  for 
life.  We  shall  return  later  to  the  delicate  question 
of  education  regarded  as  a  cause  of  nervous  de- 
bility, when  we  try  to  lay  down  the  prophylactic 
rules  to  which  those  must  be  subjected  whose 
heredity  predisposes  them  to  neurasthenia. 

!The  third  group  is  not  given  by  the  author.  It  consists  pre- 
sumably of  those  cases  in  which  neuro-arthritic  heredity  plays  no 
part  at  all.  See  page  17.  For  the  subject-matter  of  the  last  two 
paragraphs,  see  Introduction. — Trans. 


CHAPTER  III. 
EXCITING  CAUSES. 

We  have  just  seen  that  nervous  or  arthritic 
heredity,  when  it  acts  in  a  massive  dose,  so  to 
speak,  is  capable  by  itself  of  giving  rise  to  neuras- 
thenia ;  but  that  in  by  far  the  larger  number  of 
cases  its  action  is  limited  to  preparing  the  soil  on 
which  accidental  or  exciting  causes  will  later  make 
the  disease  spring  forth.  Having  thus  defined 
the  part  played  by  hereditary  defects,  we  must 
now  recall  the  fact  that  their  intervention  is  by  no 
means  necessary.  Neurasthenia  may  develop  in 
an  individual  hitherto  quite  free  from  it,  and  from 
any  congenital  taint,  by  the  sole  action  of  the  de- 
termining causes  that  we  are  now  about  to  consider. 

Over  Brain-Pressure. — The  study  of  the  general 
causes  of  nervous  asthenia  has  already  enabled  us 
to  foresee  that  over  brain-pressure  is  one  of  the 
most  powerful  factors  of  that  state.  Now  the  ex- 
amination of  individual  cases  and  observations  cor- 
roborates this  assertion  in  all  points.  Thus  all  ob- 
servers agree  in  recognising  that  exaggerated 
action  of  the  brain  is  one  of  the  most  effective 
causes,  if  not  the  most  effective  cause,  of  nervous 

Neurasthenia  2 


18  NEURASTHENIA. 

exhaustion.  But  the  term  over  brain-pressure  is 
vague,  because  it  is  too  comprehensive.  It  is  evi- 
dent that  the  brain  may  be  subjected  in  many  ways 
to  over-pressure,  and  as  among  the  modes  of  cere- 
bral activity  there  are  some  peculiarly  apt  to  pro- 
duce neurasthenia,  it  is  necessary,  in  order  to  de- 
fine precisely  the  r6le  of  mental  over-pressure  in 
the  genesis  of  the  affection  we  are  considering,  to 
group  the  cases  in  natural  categories  and  to  ex- 
amine them  separately.  From  our  present  point 
of  view  it  is  convenient  to  consider  the  effects  of 
over  brain-pressure  in  the  sphere  of  the  intellec- 
tual faculties  and  in  that  of  the  emotions. 

Excess  of  Intellectual  Work. — It  is  certain  that 
intense  or  too  prolonged  intellectual  work  may 
give  rise  even  in  an  energetic  and  well-balanced 
man  to  symptoms  of  a  neurasthenic  nature,  such 
as  insomnia,  dyspepsia,  persistent  headache,  etc. 
Great  workers,  scholars,  scientists,  literary  men, 
and  young  people  preparing  for  examinations  often 
fall  at  the  time  of  professional  competitions,1 
after  a  period  of  excessive  toil,  into  a  state  of 
cerebral  depression,  mingled  with  some  symptoms 
of  excitement,  which  compels  them  to  interrupt 
their  exertions.  But  in  general  the  forms  of 
neurasthenia  that  develop  under  these  conditions 
are  neither  persistent  nor  grave.  Some  days  of 
rest,  a  stay  in  the  country,  or  a  short  hydrothera- 

1That  is,  competitive  examinations  for  entry  into  special  training 
schools  or  public  functions.  There  are  many  more  of  these  in 
France  than  in  England. — Trans. 


EXCITING  CAUSES.  19 

peutic  treatment  most  often  suffice  to  re-establish 
the  equilibrium  of  the  nervous  system  and  to  bring 
about  the  disappearance  of  the  symptoms.  The 
reason  is  that  in  reality  intellectual  work  is  one  of 
the  least  formidable  causes  of  neurasthenia.  The 
man  who,  without  anxiety,  without  other  care  than 
that  of  research,  gives  himself  up  even  passion- 
ately to  purely  speculative  studies,  is  in  hardly  any 
danger  of  falling  a  victim  to  neurasthenia.  If  he 
brings  too  lively  an  ardour  to  his  work,  or  if  he 
prolongs  his  exertions  beyond  measure,  the  result 
will  be  a  state  of  fatigue  more  or  less  profound 
according  to  the  degree  of  resistance  of  his  brain, 
and  nothing  more.  Fatigue,  and  the  embarrass- 
ment of  cerebral  activity  that  follows  it,  will  of 
themselves  put  an  end  to  this  over-pressure,  or 
will  at  least  restrain  it  within  just  bounds ;  the 
nervous  exhaustion  that  may  result  from  it  will  in 
such  a  case  be  speedily  reparable.  We  venture  to 
affirm  then  that,  apart  from  very  rare  exceptions, 
intellectual  over-work  properly  so-called  is  incap- 
able of  engendering  a  persistent  neurasthenia ;  pro- 
vided always  that  hereditary  defects  or  depressing 
emotions  do  not  intervene,  as  most  often  happens, 
to  add  their  pernicious  influence  to  the  excess  of 
intellectual  work.  Depressing  emotions  in  reality 
constitute  a  source  of  fatigue,  a  cause  of  wear 
and  tear  to  the  nervous  centres,  far  more  powerful 
than  brain-work.  Mosso  has  demonstrated  this 
experimentally  and  has  shown  that  emotions  exert 


20  NEURASTHENIA. 

a  much  more  marked  effect  on  the  circulation  of 
the  encephalon  than  does  intellectual  work,  no 
matter  how  great  its  energy  may  be.  In  truth,  if 
neurasthenia  is  especially  frequent  in  the  cultivated 
classes  and  among  individuals  engaged  in  profes- 
sions that  exact  habitual  and  sustained  intellectual 
toil,  it  is  not  to  the  cerebral  exertion  itself  that 
the  evil  must  be  attributed,  but  much  rather  to  the 
moral  cares,  which  are  more  common,  and  es- 
pecially more  keenly  felt,  in  certain  social  con- 
ditions. The  brain-work  that  over-drives  and  ex- 
hausts is  that  which  accompanies  care  for  the 
morrow,  worry  caused  by  an  end  to  attain,  or  fear 
of  failure  or  of  a  check,  whether  the  matter  at  issue 
be  one  of  industrial  or  commercial  affairs  in  which 
the  fortune  is  engaged,  or  one  of  an  examination 
or  competition  on  which  the  future  depends.  Under 
such  circumstances  the  part  that  work,  in  the  strict 
sense  of  the  word,  plays  in  the  pathogeny  of  the 
neurosis  seems  to  us  almost  nil  or  at  least  very 
accessory,  the  true  cause  of  the  nervous  exhaus- 
tion being  the  disquiet  and  anxiety  in  the  midst  of 
which  the  work  has  been  accomplished,  the  worry 
that  has  preceded,  accompanied,  or  followed  it. 
Account  must  also  be  taken  of  the  defective  physi- 
cal conditions  in  which  the  majority  of  those  live 
whose  social  circumstances  compel  them  to  brain- 
work  more  or  less  intense.  Thus  if  one  did  not 
take  care  to  allow  for  the  part  played  by  theetiologi- 
cal  elements  that  accompany  the  supposed  over 


EXCITING  CAUSES.  21 

brain-pressure,  one  would  run  the  risk  of  greatly 
exaggerating  the  share  of  this  last.  This  is  the 
error  that  seems  to  us  to  have  been  committed  by 
those  educationalists  and  physicians  who,  especi- 
ally in  these  latter  times,  have  given  prominence 
to  the  evil  effects  of  what  to-day  is  called  over- 
pressure in  schools.  It  is  necessary  for  us  to  say 
some  words  on  this  subject. 

Over-Pressure  in  Schools. — The  question  of 
over-pressure  in  schools  is  closely  connected  with 
excesses  of  intellectual  work  considered  as  causes 
of  neurasthenia.  For  the  last  ten  years  it  has  filled 
an  important  place  in  the  preoccupations  of  hy- 
gienists.  It  has  been  the  object  of  very  keen  dis- 
cussions in  the  press,  in  the  Academies,  and  even 
in  the  Parliaments  of  different  countries,  and  the 
stirring  of  opinion  that  has  taken  place  round  it 
has  had  for  result  an  appreciable  improvement  in 
our  scholastic  system.  But  the  reform  is  still  far 
from  being  satisfactory  and  complete.  We  shall 
return  later  to  this  subject,  when  we  try  to  indi- 
cate the  hygienic  rules  that  should  govern  the 
physical  and  moral  education  of  children,  especi- 
ally of  those  who  are  predisposed  by  heredity  to 
nervous  exhaustion.  For  the  present  we  shall 
limit  ourselves  to  examining  the  part  played  by 
intellectual  over-pressure,  properly  so-called,  in 
the  development  of  the  neurasthenic  symptoms 
that  school-boys  sometimes  exhibit. 

The  injurious  influence  of  cerebral  and  intellec- 


22  NEURASTHENIA. 

tual  over-pressure  in  schools  has  certainly  been 
exaggerated.  One  might  even  ask  oneself  if  it 
really  exists,  and  if  children  are  able  to  put  over- 
pressure on  their  intellectual  faculties. 

It  is  certain  that  the  physical  and  moral  health 
of  many  pupils  in  lyceums  and  schools1  leaves  much 
to  be  desired,  and  that  many  of  them  present 
manifest  symptoms  of  nervous  exhaustion.  The 
physicians  who  have  studied  the  symptoms  of  the 
fatigue  that  is  attributed  to  over  brain-pressure  in 
school-boys,  remark  that  it  shows  itself  under  two 
forms :  one  corresponds  to  symptoms  of  morbid 
excitement,  such  as  insomnia,  irritability  of 
temper,  nervous  laugh,  palpitations  ;  the  other, 
which  usually  follows  on  the  former,  corresponds 
to  signs  of  intellectual  sloth  and  inaptitude  for 
work.  It  expresses  itself  in  yawning,  in  frequent 
desire  to  sleep,  in  want  of  power  to  fix  the  atten- 
tion, and  in  an  expression  of  languor  and  sadness 
on  the  countenance,  which  is  pale  and  drawn. 

Statistics  have  been  given.  Out  of  a  total  of 
588  pupils  in  the  middle  classes  of  secondary 
schools,  Nesteroff2  found  that  30  per  cent,  pre- 
sented symptoms  of  neurasthenia,  such  as  palpi- 
tation, persistent  headache,  insomnia,  intractable 
neuralgias.  He  noticed  that  the  proportion  of 

l"  Lycees  et  colleges."  Lycees  are  government  schools  in  the 
chief  towns  of  departments  ;  colleges  are  either  government  schools 
in  smaller  towns  or  private  schools. — Trans. 

2Die  modtrne  Schule  und  die  Gesundhcit.  Zeitschrift  /.  Schulcn- 
Gfsundheit,  1890. 


EXCITING  CAUSES.  23 

those  attacked  was  greater  according  as  the  class 
to  which  they  belonged  was  higher  : 

Preparatory  Class         -      8  per  cent. 
First  „     -         -     15     „ 

Second  ,,     -        -    22     „ 

Third  „     -        -    28     „ 

Fourth  ,,     -         -     44     „ 

Fifth  „     -        -    27     „ 

Sixth  „     -         -     58     „ 

Seventh  „     -        -     64     „ 

Eighth  „     -         -     89     „ 

Even  supposing — a  thing  that  might  easily  be 
contested — that  the  nervous  troubles  that  served 
as  a  basis  for  this  enumeration  were  all  of  a  neu- 
rasthenic nature,  it  seems  to  us  impossible  to  ad- 
mit that  over  brain-pressure  was  the  only  agent 
responsible. 

It  is  evident  that  over-pressure  can  hardly  exist 
at  all  in  primary  schools.  In  secondary  schools 
there  can  be  no  doubt  that  it  exists  for  only  a 
small  number  of  the  pupils,  namely  those  who 
wish  to  attain  and  keep  the  highest  positions,  or 
those  who  are  preparing  for  an  examination.  The 
boys  who  sin  from  excess  of  zeal  are  rare ;  the 
greater  number  protect  their  own  cerebral  health 
by  spontaneously  refusing  all  excess  of  work.  Mr. 
Galton  has  very  justly  brought  this  forward  in  his 
interesting  study  of  mental  exhaustion  in  school- 
boys :l  "It  is  among  those  who  are  zealous 

IF.  Galton.    Journal  of  the  Anthropological  Institute,  Nov.  1888. 


24  NEURASTHENIA. 

and  eager,"  he  says,  "  who  have  high  aims  and 
"ideas,  who  know  themselves  to  be  mentally  gifted, 
"and  are  too  generous  to  think  much  of  their  own 
"  health,  that  the  most  frequent  victims  of  overwork 
"are  chiefly  found."  Now  the  great  majority  of 
boys  in  the  middle  forms  of  schools  are  devoid  of 
these  exceptional  qualities.  They  simply  stop 
work  when  they  are  tired,  and  rarely  push  their 
exertions  to  the  point  of  real  exhaustion.  It  is 
only  at  the  age  of  sixteen,  seventeen  and  eighteen, 
when  they  have  to  pass  examinations  or  enter  for 
competitions  in  order  to  be  admitted  into  special 
schools,  that  young  people  may  commit  real  ex- 
cesses of  brain-work.  Over-pressure  in  the  sphere 
of  the  intellectual  faculties  is  produced  only 
by  efforts  of  will  of  which  children  are  incap- 
able (Charcot).  If  then  one  considers  the  popu- 
lation of  lyceums  and  schools  in  its  entirety,  one 
sees  that,  in  spite  of  the  overburdening  of  educa- 
tional programmes,  it  escapes  almost  wholly  from 
the  injurious  influence  of  intellectual  over-pressure ; 
and  that  it  is  only  adolescents,  in  whom  will  and 
the  feeling  of  an  end  to  be  attained  are  developed, 
who  are  capable  of  putting  over-pressure  on  them- 
selves to  the  point  of  genuine  nervous  exhaustion. 
The  majority  of  the  disorders  of  the  nervous 
system  observed  in  children  and  school-boys  of 
all  ages,  which  some  have  tried  to  place  to  the 
account  of  over  brain-pressure,  are  much  rather 
the  results  of  the  defective  hygienic  conditions  in 


EXCITING  CAUSES.  25 

which  those  boys  live  who  are  subjected  to  the 
evil  discipline  of  boarding  schools  :  too  long  hours 
of  study  and  of  classes,  and  in  consequence  too 
sedentary  a  life,  prolonged  stays  in  a  vitiated  at- 
mosphere that  grows  worse  and  worse  as  the 
hours  of  work  go  on,  habits  of  onanism,  imperfect 
physical  exercise,  insufficient  hours  of  sleep.  This 
moreover  is  the  conclusion  come  to  by  those  neu- 
rologists who  have  studied  with  some  care  the 
neurasthenia  of  the  boarders  in  lyceums  and 
schools  (Hasse,  Krafft-Ebing,  Meynert,  von 
Hossling). 

Moral  Over-Pressure, — The  depressing  emotions, 
that  is  to  say,  vexation,  anxiety,  disappointments, 
remorse,  thwarted  affection,  in  a  word  all  states 
of  sorrow  and  disquiet — these  are  the  usual  causes 
of  nervous  exhaustion. 

Moral  over-pressure,  in  its  multiple  forms,  is 
certainly  the  most  powerful  and  also  the  most 
wide-spread  factor  in  the  production  of  neuras- 
thenia. We  have  noted  that  it  almost  always  as- 
sociates its  always  evil  influence  with  the  less 
effectual  and  more  uncertain  action  of  intellectual 
over-pressure,  and  that  to  it  is  due  a  great  part  of 
the  bad  results  attributed  to  the  latter.  The  same 
remark  might  be  applied  to  the  other  causes  of 
neurasthenia,  of  whatever  nature  they  be.  All 
physicians  who  have  the  opportunity  of  seeing  a 
large  number  of  neurasthenics,  and  who  take  care 
to  enquire  into  the  circumstances  in  the  midst  of 


26  NEURASTHENIA. 

which  the  disease  has  appeared,  know  that  there 
are  very  few  states  of  nervous  asthenia  at  the 
bottom  of  which  one  cannot  distinguish  some 
mental  trouble.  It  might  be  affirmed  without  ex- 
aggeration that  the  majority  of  neurasthenics  have 
been  more  or  less  affected  on  the  emotional  side. 
Among  the  causes  of  depressing  emotions  that  in- 
tervene so  often  in  such  cases,  we  must  mention 
especially  the  death  of  children,  mourning,  reverses 
of  fortune,  and  the  cares  of  material  life.  It  can 
easily  be  imagined  that  causes  of  this  order  exert 
their  influence  in  all  classes  of  society.  Thus  the 
majority  of  the  cases  of  neurasthenia  observed 
among  the  poor,  and  notably  among  hospital 
patients,  who  evidently  escape  the  other  modes  of 
over  brain-pressure,  are  dependent  on  this  origin. 
Life  in  Society. — Life  in  society  must  figure 
among  the  possible  causes  of  over-pressure.  Not 
that  it  necessarily  exacts  an  increased  expendi- 
ture of  cerebral  activity ;  but  it  exposes  those  who 
lead  it  to  multiple  sources  of  fatigue.  Although  it 
is  especially  open  to  the  idle,  it  leaves  little  time 
for  the  restful  leisure  of  one's  own  fireside,  or  the 
calm  and  cheering  distractions  of  home.  None  are 
more  busy,  it  is  said,  than  those  who  do  nothing  ; 
an  aphorism  which  is  truer  than  its  paradoxical 
appearance  might  lead  one  to  think.  One  can 
easily  be  convinced  of  this  by  picturing  to  oneself 
the  existence  led,  especially  in  the  Parisian  world,  by 
those  who  are  calledin  thecurrent  slang  "society  " 


EXCITING   CAUSES.  27 

men  and  women.  Those  who  go  out  much, 
and  especially  women,  have  their  whole  day  taken 
up  by  the  duties  that  convention  and  the  vain  care 
of  their  reputation  impose  on  them  :  visits,  dinners, 
balls,  and  evening  parties  make  their  life  one  of 
continual  constraint,  and  of  obligations  without 
respite.  Fashion,  which  has  introduced  among 
us  for  the  present  a  tendency  to  copy  English 
habits,  and  which  has  momentarily  (for  every 
fashion  is  short-lived)  caused  a  taste  for  passing 
the  morning  in  open-air  walks  and  athletic  sports  to 
enter  into  the  manners  of  "select"  people,  mitigates 
in  a  certain  measure,  it  must  be  said,  the  serious 
disadvantages  of  a  style  of  existence  contrary  to 
all  the  rules  of  hygiene.  It  mitigates,  but  does  not 
abolish  them.  If  one  reflects  on  the  conditions  of 
life  in  society,  as  it  is  led  among  us  (and  M. 
Melchior  de  Vogue  has  shown  that  in  this  respect 
Russia  is  not  behind  us),  on  the  excitements  of 
all  sorts  that  it  occasions,  on  the  physical  fatigues 
that  it  brings  on,  and  that  almost  inevitably  result 
from  the  habit  of  too  long  and  too  copious  meals  in 
rooms  that  are  often  over-heated,  on  late  hours, 
and  on  insufficiency  of  sleep,  at  least  of  sleep  at  the 
proper  times,  one  will  not  be  astonished  that  it 
frequently  causes  the  development  of  nervous  as- 
thenia. This  is  all  the  more  easily  understood 
because  such  a  wholly  artificial  and  fictitious  exist- 
ence almost  necessarily  brings  in  its  train  a  sort 
of  moral  over-pressure,  due  to  the  paltry  efforts 


28  NEURASTHENIA. 

made  to  realise  the  whims  of  vanity,  or  to  the  vexa- 
tions of  self-esteem  that  the  incomplete  satisfac- 
tion of  those  whims  occasions.  Nothing  is  so  ener- 
vating, nothing  so  fitted  to  unbalance  and  weaken 
the  nervous  system,  as  to  be  wholly  taken  up  with 
the  pursuit  of  pleasure  and  the  satisfaction  of  the 
least  elevated  and  least  noble  desires.  A  lively 
interest  in  the  useful  part  that  each  of  us  can  fill  in 
his  position  according  to  his  aptitudes  and  facul- 
ties, is  not  only  a  moralising  element,  but  is  also 
in  certain  respects  a  condition  of  health ;  and 
neurasthenia  is  often  the  natural  but  regrettable 
penalty  paid  by  uselessness,  idleness,  and  vanity. 
Muscular  Over-Pressure. — Is  muscular  over- 
pressure also  capable  by  itself  of  engendering 
neurasthenia?  This  does  not  seem  to  us  abso- 
lutely demonstrated.  The  examples  quoted  are 
rare,  provided  always  that  care  is  taken,  as  it 
should  be,  to  count  only  those  cases  in  which  ex- 
cessive muscular  work  appears  to  be  the  sole 
etiological  factor  that  can  be  incriminated.  For 
our  own  part,  we  have  not  observed  a  single  case 
of  this  nature,  but  they  are  found  here  and  there 
among  authors.  Such  is  the  case  whose  history 
M.  Bouveret  has  related,  which  concerns  a  smith 
employed  for  ten  years  in  ironworks  at  particu- 
larly laborious  work,  necessitating  a  considerable 
expenditure  of  muscular  force.  This  man  did 
not  exhibit  any  symptoms  of  organic  affection  of 
the  nervous  centres  ;  but  he  complained  of  a  dull 


EXCITING  CAUSES.  29 

continuous  pain  in  the  forehead  and  at  the  back 
of  the  neck,  and  he  suffered  from  insomnia  and 
from  such  weakness  that  after  walking  for  a  few 
minutes  he  felt  more  or  less  exhausted.  More- 
over he  had  become  so  impressionable  as  to  be 
seized  with  trembling  on  the  slightest  emotion. 

This  case  seems  convincing ;  but  it  would  have 
been  still  more  so  if  mention  had  been  made  that  there 
had  been  no  uneasiness,  no  acute  worry,  and  no 
moral  shock  in  addition  to  the  physical  over-pres- 
sure, which  had  done  their  share  in  depressing  this 
robust  workman,and  aided  in  the  development  of  his 
malady.  In  this  connection  we  have  recently  come 
across  the  following  case,  which  is  not  wanting  in 
interest.  The  patient  was  a  young  fencing-master 
who  exhibited  all  the  signs  of  confirmed  neuras- 
thenia. As  this  man  had  felt  the  first  attacks  of 
his  illness  after  a  series  of  violent  and  prolonged 
assaults,  it  was  thought  that  it  should  be  attributed, 
as  he  attributed  it  himself,  to  the  excess  of  mus- 
cular fatigue  imposed  on  him.  But  on  questioning 
the  patient  it  was  learnt  that  the  excessive  muscular 
work  that  he  had  indulged  in  had  taken  place  in 
preparation  for  a  fencing  tournament,  the  result 
of  which  was  of  the  highest  importance.  During 
the  days  that  preceded  the  public  assault  in  which 
he  was  to  appear,  this  young  man  had  been  in 
such  a  state  of  over-excitement  that  he  had  lost 
his  appetite  and  his  sleep.  The  result  of  the  ordeal 
having  been  to  his  disadvantage,  he  was  seized  with 


30  NEURASTHENIA. 

keen  vexation,  and  became  gloomy,  depressed,  and 
subject  to  frequent  headaches  ;  he  grew  more  and 
more  uneasy  about  his  condition,  and  finally  fell  into 
confirmed  neurasthenia.  Evidently,  in  this  case, 
physical  over-pressure  seems  at  the  first  glance  to 
have  been  the  sole  cause  of  the  nervous  exhaustion ; 
and  yet  everything  warrants  us  in  holding  that  the 
uneasy  preoccupation  in  which  the  patient  lived 
while  waiting  for  an  ordeal  very  important  for  him, 
and  the  discouragement  that  followed  his  failure, 
played  some  part,probably  the  essential  and  perhaps 
the  sole  part,  in  the  genesis  of  his  complaint.  We 
have  been  anxious  to  cite  this  case,  because  it 
shows  clearly  how  easy  it  is,  in  the  absence  of  a 
careful  inquiry,  to  attribute  to  this  or  that  etiologi- 
cal  element — to  muscular  over-pressure  in  the  pre- 
sent instance — a  pathogenic  influence  that  it  does 
not  really  possess.  It  seems  to  us  that  this  remark 
is  applicable  to  the  few  cases  of  neurasthenia  from 
muscular  over-pressure  that  have  been  published 
up  till  now.  To  sum  up,  it  does  not  appear  to  us 
proved  that  exaggerated  activity  of  motor  centres 
and  muscles  can  give  rise  to  lasting  nervous 
exhaustion.  Cases  of  this  kind,  if  they  exist  at  all, 
must  certainly  be  very  rare. 

Intoxications. — Intoxications,  or  at  least  the 
habitual  and  prolonged  abuse  of  toxic  substances, 
incontestably  figure  among  the  etiological  factors 
of  neurasthenia.  In  this  respect  we  must  mention 
above  all  the  abuse  of  alcohol  and  tobacco,  and  the 


EXCITING  CAUSES.  31 

use  of  morphine  and  cocaine,  whether  taken  by  the 
stomach  or  subcutaneously. 

But  we  must  first  come  to  an  understanding  as 
to  the  action  of  these  substances  on  the  nervous 
system.  We  know  that  certain  poisons,  especially 
alcohol  and  cocaine,  produce  on  the  brain  and 
spinal  cord  effects  that  are  to  some  extent  specific, 
in  virtue  of  which  those  organs  react  in  ways  that 
vary  according  to  the  nature  of  the  toxic  agent  that 
has  affected  them.  The  hallucinations  of  the 
alcoholic  are  not  the  same  as  those  of  the  cocain- 
ist;  the  symptomatology  of  morphinomania  differs, 
it  is  needless  to  say,  from  that  of  nicotinism.  Now 
neurasthenia,  when  it  is  due  to  one  or  more  of  the 
intoxications  of  which  we  have  just  spoken,  does 
not  present  special  features  connected  with  the 
special  cause  that  has  produced  it. 

This  seems  to  show  that  if  toxic  substances  are 
able  to  bring  about  neurasthenia,  it  is  in  virtue  of  a 
general,  and  perhaps  indirect,  action  on  the  nervous 
system,  very  different  from  their  specific  action. 

And,  in  fact,  it  seems  in  such  cases  that  the 
derangements  of  digestion,  nutrition,  and  sleep 
that  are  common  among  those  who  abuse  these 
poisons,  as  well  as  the  peculiar  moral  condition  of 
the  majority  of  such  persons,  are  not  unconnected 
with  the  genesis  of  the  neurasthenic  state. 

Among  the  intoxications  that  sometimes  provoke 
this  state,  mention  must  also  be  made  of  certain  pro- 
fessional intoxications,  notably  those  due  to  lead, 


32  NEURASTHENIA. 

mercury,  and  bisulphide  of  carbon.  But  in  this 
class  of  cases,  phenomena  of  a  hysterical  nature  are 
known  to  be  usually  associated  with  the  symptoms 
of  neurasthenia  ;  one  has  then  to  do  with  hystero- 
neurasthenia,  of  which  the  poisons  that  we  have 
just  enumerated  are  powerful  exciting  agents. 

Various  Infective  and  Organic  Diseases, — It  is 
well-known  how  capable  infective  diseases  are  of 
deranging,  by  changes  that  are  either  fine  or 
coarse,  the  nutrition  of  the  brain,  spinal  cord,  and 
nerves.  By  determining  vascular  disorders  and  by 
throwing  toxins  into  the  organism,  they  frequently 
impair  the  anatomical  and  functional  integrity  of 
the  nervous  elements.  Thus  the  majority  of  the 
authors  who  have  written  on  neurasthenia  have 
ranked  infective  states  among  its  most  efficacious 
causes  (Beard,  Hamilton,  Berger). 

Typhoid  fever,  influenza,  and  malaria  have  been 
especially  incriminated.  It  is  sometimes  in  the 
course  of  convalescence,  but  most  usually  when  the 
general  health  of  the  patients  seems  to  have  been 
already  restored  to  its  normal  state,  that  the  first 
symptoms  of  the  neurosis  are  seen  to  appear.  We 
do  not  deny  that  the  various  infections  may  them- 
selves give  rise,  apart  from  all  hereditary  predis- 
position, to  a  well-marked  neurasthenic  state ;  but 
we  think  that  in  the  majority  of  cases  the  infective 
malady  acts  chiefly  as  a  predisposing  cause,  by 
diminishing  the  resistance  of  the  nervous  centres 
and  rendering  them  more  vulnerable.  On  carefully 


EXCITING  CAUSES.  33 

questioning  patients  of  this  class,  one  frequently 
finds  that  their  neurasthenia  did  not  appear  till 
after  an  emotion,  a  fright,  or  vexations  had  come 
to  agitate  their  brains  during  convalescence. 
This  is  especially  true  of  syphilis  (Fournier),  blen- 
orrhagia,  venereal  diseases  in  general,  which  are 
all  of  them  powerful  factors  in  the  production  of 
neurasthenia,  but  which  act  principally  through 
the  medium  of  the  fear,  the  distress,  and  the  dis- 
quiet into  which  they  throw  the  greater  number 
of  the  patients  attacked  by  them.1  The  same  is 
true  of  tuberculosis,  Bright's  disease,  and  heart 
complaints.  These  are  only  accessory  causes,  and 
would  doubtless  be  insufficient  to  give  rise  to  the 
neurosis  if  they  were  not  at  the  same  time  a  source 
of  alarm,  of  gloomy  thoughts,  and  of  distressing 
worries  for  those  whom  they  affect.  Nevertheless 
the  part  played  by  the  moral  element  in  the  gene- 
sis of  neurasthenia  must  not  be  exaggerated ;  and 
we  have  no  doubt  that  certain  infective  diseases 
may  exceptionally  be  the  sole  cause  of  the  affection. 
This  is  so  at  least  in  the  case  of  influenza,  the 
affinities  of  which  for  the  nervous  system  are  well 
known,  and  which  is  frequently  found  at  the  origin 
of  neurasthenia. 

Charcot  has  shown  that  neurasthenia,  like  hys- 
teria,  sometimes  associates   its  symptoms  with 

!Dr.  Dana  holds  that  "  antisyphilitic  treatment  can  certainly 
"  bring  on  or  bring  out  a  neurasthenia.  A  combination  of  secondary 
"  syphilis  with  the  excessive  use  of  alcohol  leads  to  a  very  obstinate 
"  type  of  neurasthenia."  (Twentieth  Century  Practice  of  Medicine, 
Vol.  X.,  p.  740).— Trans. 

Neurasthenia  3 


34  NEURASTHENIA. 

those  of  organic  diseases  of  the  nervous  system. 
In  fact  it  is  not  rare  to  see  well-marked  neuras- 
thenic conditions  associated  with  spasmodic  spinal 
paralysis,  or  disseminated  sclerosis  of  the  cord,  or 
locomotor  ataxy,  or  even  with  general  paralysis 


Here  again  it  seems  to  us  more  just  to  blame 
the  worry  and  profound  gloom  that  the  thought  of 
a  grave  and  incurable  malady  keeps  up  in  a  culti- 
vated mind,  than  to  suppose  that  some  vague  in- 
fluence is  exerted  by  the  spinal  lesions  on  the 
other  nervous  centres,  and  that  this  influence  pro- 
duces by  a  sort  of  action  at  a  distance  the  slight 
disorder  from  which  the  symptoms  of  nervous  ex- 
haustion proceed. 

Frights  andTraumatisms,  —  Neurasthenia  some- 
times develops  under  the  immediate  influence  of 
an  intense  and  sudden  emotion,  and  especially  of 
a  sharp  fright.  In  fact  this  emotional  state  is  able 
to  bring  on  in  a  few  days,  or  even  in  a  few  hours, 
the  appearance  of  the  characteristic  symptoms  of 
nervous  exhaustion.  All  authors  who  have  written 
on  the  causes  of  neurasthenia  and  on  the  pathology 
of  the  emotions  have  seen  and  related  cases  of  this 
kind. 

It  is  to  the  fright  occasioned  by  accidents,  with 
their  often  dramatic  circumstances,  that  the  ma- 
jority of  the  cases  of  traumatic  neurasthenia  must 
be  referred.  We  shall  say  some  words  later  on 
this  form  of  the  affection,  which  is  principally 


EXCITING  CAUSES.  35 

observed  as  a  sequel  to  great  shocks  provoked  by 
public  catastrophes  (railway  accidents,  earth- 
quakes, etc.).  The  mental  shock  in  these  cases 
plays  a  much  more  important  part  than  the 
physical,  the  proof  being  that  it  is  not  in  the  most 
seriously  injured  persons  that  the  affection 
develops. 

Dyspepsia, — Genital  Disorders. — Utero-ovarian 
Affections. — It  is  a  very  generally  accepted  opinion 
that  certain  dyspeptic  states,  certain  genital  dis- 
orders, and  utero- ovarian  affections  in  women  are 
sometimes  the  starting-point  and  first  cause  of 
neurasthenia.  On  these  data  have  been  built  a 
certain  number  of  pathogenic  theories  which  we 
shall  set  forth  later  in  a  special  chapter.  As  dis- 
orders of  the  same  kind,  affecting  the  same  systems 
(stomach,  intestines,  genital  organs),  form  an  in- 
tegral part  of  the  clinical  picture  of  neurasthenia, 
the  discussion  of  their  relations  to  it  will  be  best 
deferred  till  after  the  description  of  the  symptoms 
and  forms  of  the  disease.1 

Summary. — At  the  conclusion  of  this  rapid 
analytical  study  of  the  causes  of  neurasthenia,  let 
us  cast  a  glance  backwards  on  the  positions  that 
we  have  just  developed,  in  order  to  sum  them  up 
and  to  foreshadow  briefly  their  practical  bearing. 

All  the  causes  that  we  have  enumerated  have 
not  the  same  efficacy  nor  the  same  frequency.  The 

iQther  exciting  causes  are :  frequent  child-bearing,  lactation, 
relaxing  climates  (see  p.  322,  lines  1  to  3),  and  auto-intoxication 
(see  p.  129,  lines  1  to  3). — Trans. 


36  NEURASTHENIA. 

predisposing  cause  above  all  others,  that  which 
prepares  the  ground  in  the  greater  number  of 
cases,  and  facilitates  the  action  of  the  exciting  etio- 
logical  elements,  is  neuro-arthritic  heredity. 

Its  intervention,  however  common  it  be,  is  yet 
not  indispensable.  There  is  no  doubt  that  neuras- 
thenia can  be  brought  into  existence  de  novo ;  one 
may  even  say  that  it  constitutes  one  of  the  gates  of 
entry,  perhaps  the  principal  gate,  into  the  ground 
of  pathological  heredity ;  it  is  the  first  bough 
of  the  genealogical  tree,  with  its  many  and  bushy 
branches,  that  represents  the  neuropathic  family. 

In  addition  to  heredity,  but  after  it,  come  :  first, 
bad  education,  which  allows  the  original  vices  of 
constitution  to  develop  freely,  and  which  sends 
forth  into  life  subjects  badly  prepared  for  the 
struggle,  and  physically  and  morally  enfeebled ; 
then  puberty,  with  its  new  sensations,  and  the 
thoughts  and  appetites  it  gives  birth  to,  which,  if 
ill-regulated,  may  profoundly  disorder  the  nervous 
equilibrium. 

Then  come  all  the  exciting  causes,  weak  or 
powerful,  acute  or  chronic,  sufficing  or  secondary, 
the  common  effect  of  all  of  which  is  to  weaken 
the  nervous  system  or  to  overpower  its  resistance : 
bad  hygiene,  exaggerated  business  cares,  excess 
of  work,  the  preoccupations  of  ambition,  abuse  of 
alcohol  and  tobacco,  acute  or  chronic  diseases, 
utero-ovarian  affections  in  women,  traumatic 
shocks,  and  above  all  depressing  emotions. 


EXCITING  CAUSES.  37 

This  study  of  the  causes  of  neurasthenia  serves 
to  give  us  the  key  of  the  indications  to  be  fulfilled 
in  the  prophylaxis  of  the  affection.  But  we  must 
not  lose  sight  of  the  fact  that,  in  reality,  the  etio- 
logical  factors  concerned  are  almost  always  mul- 
tiple. It  is  not  the  easiest  part  of  the  physician's 
task  to  discover  which  are  principal  and  which  ac- 
cessory among  these  factors,  and  yet  he  must  not 
forget  that  on  the  appreciation  of  the  part  played 
by  each  of  them  depend,  in  great  measure,  the 
hygienic  rules  to  be  laid  down  and  the  therapeutic 
treatment  to  be  prescribed. 


PART  III. 

SYMPTOMS  AND  CLINICAL  FORMS  OF 
NEURASTHENIA. 

CHAPTER  I. 
GENERAL  PICTURE. 

The  functional  troubles  complained  of  by  neu- 
rasthenics are  both  very  many  and  very  varied. 
They  group  themselves  in  a  hundred  various  ways, 
giving  rise  in  different  cases  to  clinical  pictures  of 
very  great  diversity.  Moreover,  each  of  the 
symptoms  of  neurasthenia,  considered  by  itself, 
varies  from  one  case  to  another :  attenuated  to 
the  point  of  being  almost  negligible  in  one  patient, 
accentuated  and  disquieting  in  another,  absent  in  a 
third.  It  follows  that,  in  order  to  be  in  a  position 
to  regulate  suitably  the  therapeutic  treatment 
of  each  patient,  the  physician  must  first  enquire 
attentively  into  the  functional  disorders  present, 
and  draw  up  a  balance-sheet,  so  to  speak,  noting 
carefully  the  bearing  and  importance  of  each  of 
them.  Among  these  disorders  there  are  some  that 
are  really  of  little  importance  and  that  may  justi- 


GENERAL  PICTURE.  39 

fiably  be  neglected  ;  on  the  other  hand  there  are 
some  that,  by  reason  of  their  intensity  and  the 
function  that  they  derange  (dyspeptic  disorders 
among  others),  react  on  the  patient's  general  con- 
dition and  help  largely  to  keep  up  the  nervous 
exhaustion.  This  leads  us  to  trace,  in  the  present 
study,  not  a  methodic  description  of  all  the  signs  of 
neurasthenia,  but  a  sufficiently  explicit  picture  of 
the  principal  appearances  that  may  be  presented 
by  the  leading  symptoms  of  the  disease  and  by  the 
different  forms  that  this  last  may  assume ;  each  of 
these  indicating,  as  we  shall  see,  special  therapeu- 
tic treatment.  Now  in  practice  it  is  not  always 
easy  to  state  precisely  the  exact  form  of  a  patient's 
neurasthenia.  And  in  fact  one  frequently  runs 
against  difficulties  arising  from  the  subjective 
character  of  the  symptoms  and  from  the  patient's 
mental  state. 

There  are  few  patients  whose  examination 
demands  so  much  patience  and  tact  as  that  of 
neurasthenics.  In  the  presence  of  symptoms 
almost  completely  wanting  in  objective  characters, 
the  physician  has  no  other  means  of  information 
than  the  statements,  and  even  the  lamentations,  of 
the  invalid  ;  now  there  are  few  persons  who  are 
capable  of  precise  observation  and  exact  apprecia- 
tion of  their  own  functional  disorders.  From  the 
point  of  view  of  the  physiognomy  of  the  disease,  it 
is  customary  to  arrange  neurasthenics  into  two 
groups :  those  who  are  much  depressed,  speaking 


40  NEURASTHENIA. 

little  and  answering  badly  the  questions  put  to  them, 
and  those  who  seem  excited  and  speak  too  much. 
The  depressed  neurasthenic,  whether  he  be  a  work- 
man who  is  the  victim  of  a  traumatism,  or  a  man 
crushed  by  some  affliction,  presents  himself  under 
an  almost  uniform  aspect  that  strikes  one  at  the 
first  glance.  M.  Bouveret  has  drawn  a  very  accurate 
picture  of  him  : — "  The  patient  is  pale  and  thin, 
"  without  strength  or  courage,  and  always  sad  and 
"  dejected.  He  sees  everything  from  the  worst 
"  side.  He  rarely  smiles.  He  goes  along  with 
"  his  head  down,  avoiding  the  looks  of  others, 
"  his  eyes  languid  and  dull.  He  hardly  dares  look 
"  people  in  the  face  when  he  speaks  to  them,  and 
"  the  vagueness  of  his  look  is  as  it  were  a  sign  of 
"  powerlessness,  an  avowal  of  the  inferiority  of  his 
"  moral  strength.  He  always  has  the  gait  of  a 
"  tired  man ;  he  is  usually  very  sensitive  to  cold,  and 
"is  clothed  in  summer  almost  as  in  winter ;  his  speech 
"is  slow,  broken  and  trailing;  this  neurasthenic  is 
"  not  talkative."  So  little  talkative  is  he,  that,  if 
he  be  accompanied  by  some  friend,  one  sees  him,  at 
the  first  words  that  the  physician  addresses  to  him, 
turn  to  his  companion  as  if  to  beg  him  to  answer  in 
his  place;  just  as  general  paralytics  often  do.  If  he 
be  pressed  to  reply,  and  to  explain  the  causes  of  his 
illness  and  the  seat  of  his  sufferings,  he  does  so 
briefly  and  in  short  sentences:  "  I  have  a  headache," 
"  I  have  a  pain  in  the  stomach,"  "  I  have  pains  all 
over,"  "  I  am  tired,"  "I  am  weak,"  "I  can't  work." 


GENERAL  PICTURE.  41 

And  there  is  great  difficulty,  at  least  on  a  first 
examination,  in  getting  from  him  any  circumstan- 
tial details. 

Other  neurasthenics  present  themselves  with 
every  appearance  of  perfect  health.  They  are 
plump  and  fresh-complexioned  and  their  looks 
show  confidence.  They  are  capable  of  a  certain 
amount  of  activity.  Their  actions  are  lively,  their 
speech  ready,  and,  at  the  first  questions  put  to 
them,  they  rush  with  animation,  one  might  say  with 
pleasure,  into  an  interminable  recital  of  discom- 
forts, disagreeable  sensations,  sometimes  even 
pains,  that  contrast  with  their  healthy  appearance. 
They  hardly  inspire  pity,  and  among  those  about 
them,  witnesses  of  the  variability  both  of  their 
temper  and  of  the  symptoms  they  complain  of, 
they  usually  pass  for  "  malades  imaginaires."  To 
judge  from  Beard's  description,  this  variety  of 
neurasthenic  seems  to  be  especially  frequent 
among  the  Americans.  It  is  in  this  class  of  patients 
that  is  most  often  met  the  type  that  Charcot  has 
distinguished  by  a  picturesque  title,  "  The  man 
with  slips  of  paper."  This  man  imagines  that  the 
physician  will "  misunderstand  "  his  condition  if  he 
does  not  inform  him  of  even  the  smallest  symptom 
of  his  affection ;  he  is  afraid  of  forgetting  some 
detail  that  might  possibly  be  of  importance ;  he 
knows  the  weakness  of  his  memory  and  doubts  his 
other  faculties,  or  else  he  has  noticed  in  previous 
consultations  that  the  recital  of  his  ills  took  up  too 


42  NEURASTHENIA. 

much  time ;  and  so,  at  the  very  beginning,  or  after 
a  short  conversation,  he  brings  out  the  manuscript 
statement  of  them  in  the  form  of  a  list  or  of  a 
complicated  description. 

Between  the  two  extreme  types  of  neurasthenics 
that  we  have  just  sketched,  there  is,  as  may  easily 
be  imagined,  a  crowd  of  intermediate  forms  that 
we  cannot  describe  here.  Besides,  whatever  be 
the  class  to  which  they  belong,  whether  they  be 
excited  or  depressed,  and  however  intelligent  they 
may  be,  neurasthenics  almost  always  give,  either  in 
speaking  or  in  writing,  an  incoherent  and  diffuse 
description  of  their  functional  disorders,  which  the 
physician  can  only  accept  after  having  verified 
the  details  by  an  attentive  inquiry.  Some  des- 
cribe minutely,  with  unwearying  insistence,  symp- 
toms of  a  secondary  order,  and  hardly  mention 
those  of  real  importance.  Others  speak  abund- 
antly of  their  headache  and  their  muscular  weak- 
ness, but  deliberately  conceal  their  emotionalism, 
their  childish  fears,  their  states  of  anxiety,  and 
the  powerlessness  of  their  intellectual  faculties, 
all  symptoms  which  it  would  offend  their  self- 
esteem  to  confess. 

Consequently  the  line  of  conduct  to  be  followed 
with  these  patients  is  very  delicate  for  one  who 
wishes  to  acquire  an  exact  knowledge  of  their  patho- 
logical condition.  First  of  all  it  is  necessary  to 
gain  their  confidence  by  listening  patiently,  and  as  if 
with  interest,  to  the  long  and  confused  recital  of 


GENERAL  PICTURE.  43 

their  sufferings.  One  can  then  fix  their  attention 
on  this  or  that  functional  disorder,  and  obtain  pre- 
cise information  on  the  characters  and  intensity  of 
this  symptom.  By  proceeding  thus  with  methodi- 
cal enquiries,  prudently  directed  and  often 
repeated,  the  physician  will  be  able  little  by  little 
to  check  the  statements  of  the  patient,  separate 
the  true  from  the  false,  and  arrange  the  symptoms 
according  to  their  clinical  importance,  disentang- 
ling those  of  leading  importance  from  those  that 
are  secondary. 

In  every  case  it  is  advisable  to  search  out  and 
study  in  the  first  place  the  symptoms  that  are 
characteristic  of  nervous  exhaustion,  and  that  may 
be  called  fundamental. 


CHAPTER    II. 

LEADING  SYMPTOMS  OR  STIGMATA  OF 
NEURASTHENIA. 

In  the  total  group  of  morbid  phenomena  pre- 
sented by  neurasthenics,  there  is  a  certain  number 
of  symptoms  that  clinicians  have  been  led  to  dis- 
tinguish and  to  rank  in  some  sort  above  the  others, 
and  to  which  writers  on  nosography  are  careful 
to  give  prominence  in  their  descriptions,  because 
these  symptoms  are  in  reality  more  frequent  and 
more  characteristic  than  any  of  the  others.  Com- 
parable in  this  to  certain  permanent  and  funda- 
mental signs  of  hysteria,  they  well  deserve  the 
denomination  of  stigmata  of  neurasthenia  that 
Charcot  proposed  to  give  them.  They  are  :  per- 
sistent headache,  rachialgia,  neuro-muscular 
asthenia,  dyspepsia  from  gastro-intestinal  atony, 
insomnia,  and  finally  cerebral  depression,  sometimes 
accompanied  by  peculiar  mental  symptoms.  These 
cardinal  symptoms  usually  show  themselves  from 
the  outset  of  the  affection ;  they  constitute  its 
first  manifestations,  and  only  disappear  with  the 
disease  itself.  They  always  figure  wholly  or  in 
part  in  the  train  of  functional  disorders,  whatever 


LEADING   SYMPTOMS.  45 

be  the  form  under  which  the  neurasthenia  develops, 
or  whatever  be  its  cause.  The  neurasthenic  stig- 
mata are  valuable  landmarks  for  the  clinician. 
Besides,  it  is  not  rare  for  them  to  exist  alone  or 
almost  alone,  and  to  form  together  a  clinical  group 
of  symptoms  that  answers  exactly  to  one  of  the 
commonest  forms  of  the  disease.  The  physician 
must  consequently  set  himself  to  search  out  the 
existence  of  these  primordial  functional  disorders, 
and  to  note  their  forms  and  variations  in  each 
patient.  Some  of  them,  notably  the  digestive 
and  mental  disorders,  will  be  able  to  furnish  him, 
after  a  judicious  analysis  of  their  characters,  with 
useful  indications  from  the  therapeutical  point 
of  view. 

a.  Headache. — This  is  a  common  symptom, 
existing  in  three-quarters  of  the  cases.  The  neu- 
rasthenic headache  has  very  special  characters. 
It  is  not  painful  in  the  proper  sense  of  the  word ; 
the  sensation  is  most  often  one  of  pressure,  of 
fulness,  or  of  constriction,  which  in  the  end  reduces 
the  patients  to  despair.  It  seems  to  them,  they  say, 
that  they  carry  a  ponderous  weight  on  the  head, 
or  else  a  head-dress  too  heavy  and  too  tight.  This 
is  what  Charcot  called  the  casque  neurasthenique. 
The  headache  does  not  always  extend  over  the 
whole  cranium ;  it  is  fairly  frequently  limited  to 
the  occiput  (plaque  occipitale).  Many  patients,  in 
fact,  when  asked  the  position  of  the  pain,  im- 
mediately place  their  hands  on  the  back  of  the  neck, 


46  NEURASTHENIA. 

thus  incriminating  the  cerebellum.  On  other  oc- 
casions it  is  localised  in  the  forehead,  the  temples, 
or  the  vertex.  Certain  neurasthenics  complain 
particularly  of  a  sensation  of  pressure  and  tight- 
ness situated  at  the  root  of  the  nose  or  on  the 
eyeballs.  Others  mention  feelings  of  emptiness, 
or  of  bodies  floating  inside  the  cranial  cavity.  It 
seems  to  them  that  inside  the  skull  they  have 
something  like  a  liquid  which  moves  in  various 
directions,  and,  when  rotating  the  head,  they  often 
notice  crackings  at  the  back  of  the  neck  in  the 
upper  part  of  the  vertebral  column. 

The  neurasthenic  headache  is  sometimes  con- 
tinuous and  incessant,  but  most  frequently  it 
passes  through  alternate  phases  of  exacerbation 
and  remission,  which  usually  succeed  one  another 
in  the  following  fashion :  in  the  morning,  as  soon 
as  he  rises,  the  patient  suffers  from  headache  ;  this 
increases  in  intensity,  especially  when  he  is  fasting, 
in  the  moments  preceding  lunch  ;  during  this  meal 
it  lessens,  and  often  it  even  disappears  entirely. 
This  state  of  well-being  lasts  ordinarily  for  a 
quarter  of  an  hour  or  half  an  hour,  at  the  end  of 
which  period  the  work  of  digestion  begins  to  make 
itself  felt  with  all  the  discomforts  that  accompany 
it ;  the  heaviness  of  the  head  reappears,  at  first 
violent,  and  then  more  feeble  till  the  evening.  All 
intellectual  work,  reading,  composing  a  letter,  a 
conversation  however  short,  an  emotion,  noise,  all 
augment  the  headache.  During  the  paroxysms  the 


LEADING  SYMPTOMS.  47 

patients  sometimes  experience  so  keen  a  hyper- 
aesthesia  of  the  scalp  that  they  cannot  bear  their 
hair  to  be  touched  (Beard) ;  they  also  complain  of 
humming  in  the  ears  and  of  feelings  of  vertigo.  The 
exciting  cause  of  these  paroxysms  cannot  always 
be  discovered ;  they  sometimes  come  on  without 
apparent  reason,  and  alternate  with  longer  or 
shorter  periods  of  respite,  without  anything  to 
indicate  the  influences  that  govern  these  varia- 
tions. 

b.  Rachialgia. — The  troublesome  or  painful  sen- 
sation that  neurasthenics  experience  in  the  back, 
along  the  vertebral  column,  are  very  similar  to 
those  that  constitute  their  headache.  Rachialgia 
however  is  less  common  than  headache.  It  usually 
consists  of  sensations  of  pressure,  of  dragging,  or 
of  discomfort,1  that  may  occupy  the  various 
regions  of  the  spinal  cord,  but  are  most  often 
situated  at  the  level  of  either  the  seventh  cervical 
vertebra,  the  lumbar  vertebras,  or  the  sacrum. 
This  last  localisation  is  certainly  the  commonest 
(Charcot's  plaque  sacree). 

The  rachialgia,  however,  may  show  itself  under 
other  aspects.  Some  patients  complain  of  having, 
along  the  whole  of  the  vertebral  column,  a  sensa- 
tion of  vaguely  painful  stiffness,  or  of  aching, 
which  hampers  them  in  their  movements.  These 
deeply  situated,  more  or  less  uncomfortable  sen- 
sations, are  generally  increased  by  walking,  by 

1  or  heat,  or  burning  (see  p.  94). — Trans. 


48  NEURASTHENIA. 

standing,  by  bending  the  body  and  by  straighten- 
ing it  again,  and  in  women  at  the  period  of  the 
menses.  Sometimes  they  are  accompanied  by  a 
genuine  hyperaesthesia  of  the  skin ;  in  such  cases, 
by  pressing  even  lightly  on  the  tips  of  the  spinous 
processes,  one  can  set  up  a  keen  pain  comparable 
to  the  shooting  pains  of  neuralgias. 

When  the  rachialgia  is  so  intense,  and  really 
painful  and  tenacious,  it  is  frequently  combined 
with  sensations  of  heaviness  in  the  lower  limbs, 
and  with  hyperaesthesiae  of  the  genito-urinary 
organs.  These  are  the  cases  that  some  patholo- 
gists  have  described  under  the  name  of  spinal 
irritation ;  spinal  irritation  does  not  constitute  a 
distinct  morbid  species,  but  is  merely  a  clinical 
form  of  nervous  exhaustion. 

c.  Neuro-muscular  Asthenia. — Weakening  of  the 
motor  energy  is  one  of  the  commonest  symptoms 
of  neurasthenia.  There  are  few  neurasthenics, 
even  among  those  least  depressed,  who  have  not 
lost  a  notable  part  of  the  muscular  activity  that 
they  possessed  before  the  onset  of  their  malady. 
In  its  slighter  form  this  functional  disorder  con- 
sists simply  of  a  continual  feeling  of  fatigue, 
which  exists  in  the  morning  from  the  moment  of 
awaking,  and  which  the  majority  of  patients  com- 
plain of  spontaneously.  In  this  degree  it  does  not 
prevent  the  patient  from  attending  more  or  less 
well  to  his  daily  occupations.  When  it  attains  a 
higher  degree,  the  sufferer  complains  bitterly  of 


LEADING  SYMPTOMS.  49 

his  feebleness ;  he  cannot  complete  the  simplest 
acts  in  one  effort,  however  short,  without  immedi- 
ately feeling  an  insurmountable  lassitude.  To  stand, 
to  walk,  or  to  talk,  each  causes  him  fatigue.  It 
seems  as  if  his  reserve  of  motor  energy  were  so 
insufficient  that  the  slightest  effort  exhausts  it;  as 
Beard  remarks,  these  neurasthenics  are  always 
on  the  verge  of  muscular  fatigue ;  everything  pros- 
trates them.  One  can  easily  understand  that  this 
symptom,  when  it  is  somewhat  accentuated,  may 
interfere  seriously  with  the  patient's  mode  of  life. 
There  are  some  whose  powerlessness  to  move 
compels  them  to  abandon  their  professions. 

The  ergographic  investigations  made  by  us  in 
collaboration  with  Jean  Philippe1  have  enabled  us 
to  bring  out  clearly  certain  objective  features  of 
this  amyosthenia. 

By  means  of  the  apparatus  known  as  Mosso's 
ergograph,  the  movements  of  the  index  finger  of 
the  right  hand  are  registered  as  it  raises  a  weight 
attached  to  it  by  a  thread.  The  results  obtained 
differ  according  as  the  subject  is  healthy,  is  suffer- 
ing from  muscular  atrophy  due  to  any  cause  (myo- 
pathy,  neuritis  or  myelitis),  or  is  neurasthenic. 

In  the  case  of  the  first  of  these  (the  heal  thy  in- 
dividual— fig.  1),  if  the  finger  be  made  to  work  till 
the  moment  of  complete  exhaustion,  the  height  of 
the  tracing  showing  the  force  of  the  contractions 
becomes  progressively  less.  When  this  height 

1  G.  Ballet  and  Jean  Philippe,  Congrls  des  alienistes  et  neurologistes, 
Brussels,  1903,  and  Societe  de  Neurologic  de  Paris,  5  Nov.,  1903. 

Neurasthenia  4 


50  NEURASTHENIA. 

approaches  0,  if  the  contractions  are  then  separ- 
ated by  intervals  of  10  seconds,  it  is  found  that 
the  flexor  muscle  not  only  recovers  its  power  of 
action,  but  also  ceases  to  become  fatigued.  The 
tracings  of  the  contractions  thus  separated  are  all 
practically  of  the  same  height. 

In  patients  suffering  from  muscular  atrophy,  the 
results  are  similar  to  those  obtained  in  the  case  of 
the  healthy,  the  only  difference  being  that,  as  the 
atrophied  muscles  are  capable  only  of  feebler 
efforts,  the  height  of  the  tracing  is  less  (fig.  2). 

In  neurasthenics  (fig.  3)  the  results  are  different. 
After  reaching  the  point  of  exhaustion  the  muscle 
recovers  its  power  of  action  either  not  at  all  or 
only  very  slowly.  In  other  words,  the  interval  of 
10  seconds,  which  is  enough  to  allow  a  healthy  or 
atrophic  muscle  to  eliminate  the  fatigue  caused  by 
the  previous  contraction,  is  insufficient  to  bring 
about  a  similar  result  in  a  neurasthenic.  Fatigue 
is  more  lasting  in  the  neurasthenic  than  in  the 
healthy  man,  or  even  in  the  patient  suffering  from 
muscular  atrophy. 

Amyosthenia,  in  a  good  many  cases,  presents 
this  curious  peculiarity,  that  it  seems  to  be 
localized  in  certain  groups  of  muscles,  or  at  least 
to  manifest  itself  only  on  the  occasion  of  certain 
movements.  Here  are  some  striking  examples : 
A  pianist  is  affected  with  nervous  exhaustion  in 
consequence  of  a  violent  emotion ;  among  other 
neurasthenic  symptoms,  he  complains  of  a  singular 


FIG.  1. 
Ergogram  of  healthy  man. 


Fig.  2. 
Ergogram  of  patient  with  muscular  atrophy. 


Fig.  3. 
Ergogram  of  neurasthenic. 


All  the  figures  to  be  read  from  right  to  left,  beginning,  in  fig.  3, 

with  the  lowest  line. 


[To  face  page  50. 


LEADING  SYMPTOMS.  51 

weakness  in  his  upper  limbs ;  directly  he  begins  to 
play  the  piano  he  feels,  he  says,  a  painful  lassi- 
tude in  the  whole  length  of  his  upper  limbs,  which 
rapidly  compels  him  to  stop  playing  ;  yet  he  is 
able  to  practice  fencing  for  a  long  time  without 
feeling  any  fatigue  in  his  arms.  M.  Bouveret  re- 
lates the  following  case  :  A  business  man  be- 
came neurasthenic  after  a  fright ;  he  was  affected 
by  neuro-muscular  asthenia  in  the  lower  extremi- 
ties almost  exclusively ;  he  was  absolutely  unable 
to  remain  standing  for  more  than  ten  minutes,  at 
the  end  of  which  time  the  sensation  of  weariness 
appeared  so  quickly,  and  became  so  great,  that  he 
was  obliged  to  sit  down  or  rest  his  knee  on  a 
chair.  This  localisation  of  amyosthenia  in  the 
lower  limbs  is  especially  common  in  the  neuras- 
thenia of  women,  in  which  it  is  sometimes  the 
dominant  symptom.  Some  patients,  harassed  and 
disheartened  by  this  permanent  weakness,  gradu- 
ally give  up  both  walking  and  standing  ;  they  refuse 
to  go  out,  and  spend  their  days  lying  on  a  sofa. 

There  is  another  feature  of  this  asthenia  that 
deserves  to  be  insisted  on,  namely,  that  it  never 
goes  so  far  as  to  bring  about  a  true  paralysis,  and 
that  in  the  majority  of  cases,  although  it  is  more 
or  less  continuous,  yet  it  varies  from  day  to  day, 
one  might  almost  say  from  one  moment  to  another, 
diminishing,  disappearing,  increasing,  and  this 
from  causes  that  are  diverse,  but  chiefly  of  a 
mental  nature. 


52  NEURASTHENIA. 

When  we  study  the  mental  state  of  neuras- 
thenics, we  shall  see  that  this  motor  impotence 
depends  much  more,  at  least  in  some  cases,  on  a 
purely  psychical  disorder  than  on  rapid  exhaustion 
of  the  motor  cells  or  muscles,  as  is  generally  be- 
lieved. The  neurasthenic,  like  some  patients 
with  ataxia,  disseminated  sclerosis,  or  other 
organic  diseases  of  the  spinal  cord,  unconscious- 
ly magnifies  the  disorder  by  which  he  is 
attacked.  His  mind  comes  to  believe  in  a 
readiness  of  fatigue  and  a  loss  of  power  more 
marked  than  is  really  the  case.  It  is  in  this  way 
that  mental  processes  come  to  play  an  important 
part  in  the  patient's  subjective  disorders.  This 
view  has  some  practical  importance ;  we  shall 
see  later  what  profit  may  be  drawn  from  it  from 
the  therapeutical  point  of  view. 

d.  Insomnia. — This  symptom  of  nervous  ex- 
haustion is  not  rare,  but  it  is  far  from  being  con- 
stant ;  it  is  often  absent  in  the  neurasthenia  of 
women,  and  is  especially  found  in  the  cerebral 
form  of  neurasthenia,  when  this  has  developed 
under  the  influence  of  excessive  intellectual  work 
or  of  worry.  The  insomnia  of  neurasthenics 
shows  itself  under  varying  characters.  Among 
the  patients  affected  by  it,  there  are  some  who  go 
to  sleep  readily  as  soon  as  they  are  in  bed,  but 
after  some  instants  awake  suddenly  in  a  state  of 
excitement  that  persists,  no  matter  what  efforts 
they  make  to  calm  themselves ;  they  are  restless 


LEADING  SYMPTOMS.  53 

and  turn  about  in  their  beds,  and  it  is  only  at  an  ad- 
vanced hour  of  the  night,  or  even  at  the  approach 
of  day,  that  they  succeed  in  falling  asleep  again. 
Other  patients  go  to  bed  with  the  fear,  or  even 
the  conviction,  that  they  will  not  sleep.  And, 
in  reality,  it  is  extremely  difficult  for  them, 
often  even  impossible,  to  fall  asleep  for  a  single 
moment ;  they  are  kept  awake  by  a  sort  of  mental 
disquiet  or  incessant  cogitation,  because  their 
minds  are  harassed  by  a  rapid  flow  of  images, 
ideas,  and  memories,  in  quick  association  and  im- 
possible to  repress.  Finally,  in  a  certain  number 
of  cases,  the  insomnia  cannot  be  explained  in  any 
way  ;  it  is  purely  and  simply  the  absence  of  an  in- 
clination to  sleep.  The  person  is  calm,  his  mind 
is  at  rest,  no  thought  disquiets  or  torments  him, 
and  yet  he  cannot  sleep. 

Dreams  are  very  frequent ;  they  are  almost 
always  disagreeable,  and  the  patient  finds  himself 
in  a  painful  position  in  them ;  he  is  witness  of  some 
frightful  drama  and  runs  the  greatest  dangers,  or 
else  he  is  victim  of  a  serious  accident,  sees  himself 
pursued  by  assassins,  or  is  present,  but  helpless, 
at  the  violent  death  of  some  one  dear  to  him. 
These  nightmares  are  especially  frequent  in  cases 
of  traumatic  hystero-neurasthenia,  and  of  nervous 
exhaustion  following  on  sudden  and  violent  emo- 
tions. Such  terrifying  dreams  make  the  patients 
start,  wake  them  abruptly,  and  leave  them  in  a 
state  of  distress  or  agitation  which  for  a  long  time 


54  NEURASTHENIA. 

prevents  the  return  of  sleep.  The  dreams  of 
neurasthenics  have  not  always  these  violent  forms; 
they  may  last  the  greater  part  of  the  night  without 
breaking  the  sleep  of  the  patient,  but  such  a  sleep 
disturbed  by  incessant  dreaming  is  almost  as  little 
restorative  as  insomnia  itself,  and  one  can  easily 
understand  that,  on  waking  in  the  morning,  the  in- 
valid's brain-fatigue,  uneasiness,  and  headache  are 
quite  as  great  as  though  he  had  not  closed  an  eye 
all  night. 

e.  Disorders  of  Digestion. — Dyspeptic  States 
of  Neurasthenics. — Disorders  of  the  digestive 
functions  fill  a  very  important  place  in  the  clinical 
picture  of  neurasthenia.  Their  appearance  some- 
times marks  the  very  beginning  of  the  malady,  and 
they  usually  last  for  its  whole  duration.  Slight 
or  serious,  they  contribute,  through  the  anxieties 
and  disquietudes  that  they  give  rise  to  in  the  minds 
of  the  patients,  and  through  the  disorder  into 
which  they  throw  their  alimentation  and  assimila- 
tion, to  keep  up  or  to  increase  the  nervous  exhaus- 
tion. 

It  is  now  known  from  many  researches  that  the 
states  of  dyspepsia  observed  in  neurasthenics  by 
no  means  answer  to  a  single  formula.  Since  the 
publication  of  Leube's  account  of  nervous  dyspep- 
sia, many  authors  both  in  Germany  and  in  France 
have  studied  this  question  with  care.  Although 
their  conclusions  still  differ  in  some  important 
points,  this  essential  principle  can  nevertheless  be 


LEADING  SYMPTOMS.  55 

deduced,  that  the  dyspepsia  of  neurasthenics  is  far 
from  being  always  the  same,  and  that  the  disorder 
of  the  gastric  functions  from  which  it  proceeds  is 
variable  in  nature  and  differs  greatly  in  different 
cases.  It  follows  that  in  practice  the  physician 
must  set  himself,  by  using  all  the  means  of  infor- 
mation at  his  disposal,  to  note  as  precisely  as 
possible  the  character  and  the  degree  of  the 
dyspeptic  troubles  presented  by  each  subject.  Only 
a  methodical  analysis  of  each  individual  case  can 
lead  him  to  deductions  of  real  importance  as  to 
the  prognosis  and  treatment. 

1.  Dyspepsia  from  gastro-intestinal  atony. — 
The  most  frequent  type  of  dyspepsia  is  that  which 
has  received  the  appropriate  names  of  dyspepsia 
from  gastro-intestinal  atony  (Bouveret)  and  nervo- 
motor  dyspepsia  (Mathieu).  It  is  with  this  form 
that  we  must  begin  the  analytical  study  of  the 
digestive  disorders  that  may  be  observed  in  neu- 
rasthenics. 

The  dyspeptic  group  of  symptoms  of  which  we 
are  now  treating  is  very  common  among  subjects 
affected  with  nervous  exhaustion,  and,  whatever 
may  have  been  said  to  the  contrary,  has  characters 
sufficiently  well  marked  to  be  easily  recognised.  It 
deserves,  then,  to  have  a  place  among  the  cardinal 
symptoms  or  stigmata  of  neurasthenia.  M. 
Bouveret  has  rightly  described  two  degrees  or 
forms  of  neurasthenic  gastro-intestinal  atony,  the 
slight  and  the  severe ;  and  this  distinction  seems 


56  NEURASTHENIA. 

to  us  to  be  perfectly  justified  by  clinical  observa- 
tion. 

Slight  form. — In  its  slight  form,  atonic  dyspepsia 
does  not  appreciably  impair  the  general  nutrition 
of  the  patient.  In  spite  of  the  digestive  troubles 
from  which  he  suffers,  the  neurasthenic  keeps  up 
his  strength  and  his  plumpness  ;  he  does  not  grow 
thin,  but  he  digests  badly.  The  appetite  is  gener- 
ally preserved.  It  only  shews  itself  unequal  and 
capricious,  and  it  is  to  be  noticed  that  its  variations 
are  governed  much  more  by  the  moral  condition 
of  the  patient,  and  the  disposition  of  his  mind, 
than  by  the  state  of  his  digestive  passages.  The 
appetite  is  maintained  when  mental  depression  is 
feeble  or  absent,  and  lessens  under  the  influence 
of  some  gloomy  thought  or  distressing  emotion. 
Persistent  anorexia  is  exceptional. 

It  sometimes  happens  that  the  uneasy  feelings 
come  on  immediately  after  the  ingestion  of  food. 
And  this  early  appearance  of  the  digestive  troubles 
led  Leube  to  explain  them  by  an  abnormal,  but 
purely  mechanical,  irritation  produced  by  the  food 
on  the  terminations  of  the  sensory  nerves  of  the 
stomach.  But,  in  the  majority  of  cases,  the  func- 
tional disorders  do  not  appear  till  half  an  hour  or 
even  an  hour  after  meals.  Fairly  often  indeed 
the  patient  experiences  a  feeling  of  general  well- 
being  after  eating  and  drinking ;  his  headache 
and  lassitude  are  dispelled,  and  he  feels  himself 
stronger  and  more  able  to  work.  This  passing 


LEADING  SYMPTOMS.  57 

amelioration  has  been  attributed  to  the  absorption 
of  liquid  and  the  momentary  raising  of  arterial 
tension  caused  thereby.  However  this  be,  the 
period  of  euphoria  is  not  long  in  coming  to  an  end, 
and  then  begin  signs  of  laborious  digestion.  The 
patient  complains  of  a  sensation  of  weight,  of 
pressure,  or  of  distension  at  the  epigastrium.  His 
head  is  heavy,  his  cheeks  hot,  his  face  congested. 
The  distress  becomes  general,  and  he  suffers  from 
oppression  and  palpitations,  and  at  the  same  time 
a  feeling  of  dulness  and  torpor.  He  is  incapable 
of  any  intellectual  work ;  walking  and  movement 
in  general  trouble  him,  and  he  sometimes  falls  into 
a  state  of  overwhelming  drowsiness.  During  the 
access  of  dyspepsia,  the  abdomen  swells  in  the 
epigastric  region  first,  and  then  the  gaseous  dis- 
tension spreads  to  the  intestines,  so  much  so  that 
many  patients  are  obliged  to  loosen  their  clothing. 
If  a  physical  examination  is  made,  it  is  found  on 
percussion  that  the  gastric  resonance  extends  be- 
yond its  physiological  limits.  Sudden  pressure  on 
the  surface  produces  a  sound  of  splashing  in  this 
region,  but  this  sound  is  only  perceptible  during 
the  first  few  hours  after  the  meal ;  and  this  shows 
that  the  stomach  is  merely  distended  by  meteorism, 
not  dilated. 

While  the  gastric  digestion  is  going  on,  the 
patient  is  still  further  tormented  by  eructations  of 
inodorous  gas.  Risings  in  the  stomach  and  acid 
regurgitations  are  exceptional.  Finally,  at  the  end 


58  NEURASTHENIA. 

of  several  hours,  when  the  digestion  is  finished, 
everything  returns  into  order  till  the  next  meal, 
which  brings  back  the  same  series  of  discomforts 
and  derangements. 

The  generalisation  of  the  abdominal  meteorism, 
and  the  constipation  that  is  rarely  wanting  in  these 
cases,  indicate  that  the  neurasthenic  atony  does  not 
only  attack  the  stomach,  but  that  it  also  affects 
the  intestines. 

Constipation  is  often  established  from  the  first ; 
when  it  is  obstinate  and  resists  the  majority  of  the 
usual  purgatives,  it  happens  that  the  patients 
remain  three,  four,  or  more  days  without  going  to 
the  closet.  It  is  then  accompanied  by  meteorism 
and  by  sensations  of  weight  or  tension  in  certain 
parts  of  the  abdomen.  In  such  cases  it  becomes 
the  subject  of  constant  hypochondriacal  anxieties 
on  the  part  of  the  sufferers,  and  in  the  end  it  may 
be  complicated  by  pseudo-membranous  entero- 
colitis.  The  motor  functions  of  the  stomach  are 
not  seriously  affected  in  this  slight  form  of  atony ; 
thesigns  of  dilatation,in  the  strict  sense  of  theword, 
are  absent ;  the  sound  of  splashing  is  not  produced 
by  gastric  succussion  when  the  patient  is  fasting  ; 
and  if  the  stomach-tube  be  introduced  six  or  seven 
hours  after  a  meal,  it  is  found  that  the  contents  of 
the  organ  have  been  evacuated  in  the  normal  time. 
In  the  end,  however,  the  resistance  of  the  gastric 
walls  is  overcome. 

The  first  degree  of  atonic  dyspepsia  is  often  only 


LEADING  SYMPTOMS.  59 

the  first  stage  of  a  process  ending  in  the  following 
form. 

Severe  Form. — In  the  second  degree  of  gastro- 
intestinal atony  one  again  finds,  but  more 
developed,  more  intense,  the  same  disorders  that 
figure  in  the  clinical  picture  of  the  slight  form. 
The  dyspeptic  crisis  that  follows  meals  displays 
itself  with  the  same  train  of  symptoms.  What 
especially  characterises  this  second  form  is  that 
it  seriously  impairs  nutrition. 

The  patient  grows  thin  and  anaemic  and  loses  his 
strength ;  the  wasting  is  all  the  more  remarkable 
because  the  quantity  of  food  ingested  is  often  quite 
enough,and  would  assuredly  suffice  for  the  mainten- 
ance of  a  man  in  good  health.  It  is  usually  rapid. 
In  a  few  months  the  patient  sustains  a  reduction  in 
weight  of  20  or  30  Ibs.,  and  sometimes  more.  In 
severe  cases,  especially  when  the  nervous  exhaustion 
has  been  provoked  by  a  sudden  and  violent  emotion, 
and  is  accompanied  by  intense  mental  depression, 
the  thinness  is  sometimes  extreme ;  the  skin  becomes 
dry  and  earthy ;  the  face  emaciates,  and  the  aspect 
of  the  patient  is  that  of  one  suffering  from  cancer- 
ous cachexia;  and  in  fact  it  often  happens  that  these 
invalids  are  considered  as  attacked  by  gastric 
cancer.  Another  remarkable  feature  of  the  severe 
form  of  neurasthenic  gastro-intestinal  atony  is  its 
tenacity,  its  long  duration,  its  resistance  to  the 
methods  of  treatment  usually  employed  against 
dyspeptic  conditions ;  this  is  especially  the  case 


60  NEURASTHENIA. 

with  neurasthenics  advanced  in  years.  In  young 
people,  endowed  with  greater  vitality,  a  notable 
amelioration  of  the  general  condition  is  sometimes 
obtained,  but  recurrences  are  frequent,  and  cure, 
when  it  is  effected,  is  slow  and  interrupted. 

The  motor  functions  of  the  stomach  are  here  more 
seriously  affected,  and  it  is  not  rare  for  the  stomach 
still  to  contain  food  seven  hours  after  an  ordinary 
meal.  Dilatation  may  however  be  absent  in  the 
severest  forms,  and  in  the  majority  of  cases  it  is  by 
no  means  appreciable  till  after  several  years  of 
dyspepsia. 

2.  Disorders  of  the  gastric  secretion.  Patho- 
logical chemistry  of  the  stomach. — Formerly  an 
analysis  of  the  gastric  juice  of  neurasthenics 
used  frequently  to  be  made.  If  this  operation 
has  lost  much  of  its  practical  utility,  it  has 
at  least  served  to  fix  certain  questions  of  gastric 
chemistry  which  are  not  without  interest.  It 
is  true  that  those  clinicians  who  have  studied 
the  character  of  the  gastric  secretions  in 
subjects  attacked  by  nervous  exhaustion,  have 
arrived  at  dissimilar  results.  We  must  here 
recall  briefly  the  essential  conclusions  to  which 
their  researches  have  led. 

In  the  gastro-intestinal  atony  of  neurasthenics, 
M.  Bouveret  states  that  the  secretion  of  the 
stomach  has  undergone  important  qualitative 
modifications.  According  to  him,  the  principal  fact, 
or  at  least  the  one  that  can  be  best  appreciated  at 


LEADING  SYMPTOMS.  61 

present,  is  diminution,  or  even  total  disappearance, 
of  the  free  hydrochloric  acid  of  the  gastric  juice 
at  all  periods  of  digestion.  "  It  is  even  more 
"  common  to  observe  its  complete  absence  than 
"  its  simple  diminution  in  those  patients  who  are 
"  true  neurasthenics."  He  adds  that  this  absence 
of  hydrochloric  acid  is  an  early  feature,  since 
it  appears  in  the  first  degree  of  gastro-intestinal 
atony,  and  that  it  is  tenacious  and  resistant  to  treat- 
ment. Insufficience  or  absence  of  hydrochloric  acid 
must  then,  according  to  this  author,  be  considered 
as  an  important  element  in  atonic  dyspepsia.  M. 
Bouveret  remarks,  however,  that  patients  who 
present  the  slight  form  of  this  dyspepsia  waste 
little  or  not  at  all,  in  spite  of  the  real  disturb- 
ance of  the  chemical  functions  of  the  stomach, 
and  he  supposes  that  either  the  intestinal  and 
pancreatic  secretions  make  up  for  the  deficien- 
cies of  the  gastric  juice,  or  hydrochloric  acid 
does  exist  in  that  fluid,  but  in  such  feeble  pro- 
portions that,  directly  it  is  produced,  it  is  masked 
by  the  albuminoids  of  the  food  or  by  peptones. 
In  the  latter  case  the  process  of  peptonisation 
in  the  stomach  would  be  slowed,  but  would  still 
be  possible. 

As  to  the  proportion  of  pepsine  contained  in  the 
gastric  juice,  he  holds  that  it  is  practically  normal. 

Finally,  the  total  acidity  due  to  combined  organic 
acids  and  hydrochloric  acid  is,  he  believes,  slightly 
above  the  physiological  average.  In  the  severe 


62  NEURASTHENIA. 

forms  of  neurasthenic  atony,  this  indicates,  as  does 
the  development  of  gas  in  the  stomach  during 
digestion,  the  existence  of  abnormal  fermentations 
of  the  chyme,  these  fermentations  being  them- 
selves attributable  to  the  weakened  antiseptic 
power  of  the  gastric  juice  when  it  is  deprived  of 
free  hydrochloric  acid. 

M.  Bouveret  has  observed  excess  of  hydrochloric 
acid,  and  of  the  gastric  secretion  generally,  in  only 
a  very  small  number  of  cases ;  he  considers  that 
this  is  a  matter  of  fortuitous  association,  and  that 
cases  of  this  class  should  not  be  considered  as 
atonic  nervous  dyspepsia  properly  so-called 
(Traite  des  maladies  de  I'estomac,  1893). 

The  researches  of  M.  Mathieu  have  led  him  to 
results  that  differ  appreciably  from  the  preceding. 

In  cases  that  answer  to  the  slight  form  of  nervo- 
motor  dyspepsia,  or  to  gastro-intestinal  atony  of  the 
first  degree,  this  author  has  fairly  often  observed 
that  digestion  is  performed  under  almost  normal 
chemical  conditions,  that  free  hydrochloric  acid 
exists,  though  in  slightly  smaller  proportion  than  in 
the  physiological  state,  and  that  pepsine  also  is  pro- 
duced in  proportions  that  do  not  seem  to  differ  much 
from  those  of  health,  in  so  far  at  least  as  one  can 
judge  from  digestions  artificially  carried  out  with 
filtered  gastric  juice  ;  and  that,  finally,  the  quantity 
of  the  organic  acids  of  fermentation  is  not  appre- 
ciably increased. 

In  severe  cases,  on  the  other  hand,  M.  Mathieu 


LEADING  SYMPTOMS.  63 

observed  that  there  is  often  a  marked  diminution  in 
the  secretion  of  hydrochloric  acid,  the  free  acid 
being  absent,  and  the  combined  acid  in  small  quan- 
tities ;  and  that  the  total  acidity  is  either  normal  or 
above  normal,according  as  stasis  and  fermentation 
are  wanting  or  are  present  to  a  considerable 
degree.  M.  Mathieu  states,  moreover,  that  hyper- 
secretion  of  hydrochloric  acid  may  be  observed 
in  neurasthenia,  and  that  it  is  certainly  less  rare 
than  M.  Bouveret  believes. 

Herzog1  has  published  an  important  paper  on 
this  subject.  In  14  cases  of  nervous  dyspep- 
sia under  the  care  of  Leyden,  the  author  found  that 
the  motor  functions  of  the  stomach  were  impaired 
in  9  and  normal  in  5.  Of  the  9  patients  in  whom 
the  motor  functions  were  impaired,  3  had  normal 
acidity,  1  feeble  acidity,  and  5  showed  either  hyper- 
secretion  of  hydrochloric  acid  or  hyperacidity  in 
general.  Among  the  5  patients  in  whom  the  motor 
functions  were  intact,  there  were  1  case  of  normal 
acidity  and  4  of  hyperacidity.  According  to  this 
author,  then,  the  disorder  of  the  gastric  functions 
consists  most  often  in  impairment  of  motility  with 
exaggerated  secretion  and  hyperacidity. 

The  researches  of  Leyden2  and  Stiller8  had 
already  shown  that,  contrary  to  the  opinion  of 
Leube,  nervous  dyspepsia  may  provoke  serious 
disorders  of  the  secretion  and  the  motor  functions. 

iHerzog,  Zeitschrift  f.  Klin.  Med.,  Bd.,  XVIII.,  1890. 
SLeyden,  Berliner  Klin.  Wochenschr.,  1885. 
8Stiller,  Die  nervose  Magenkrankheiten,  1884. 


64  NEURASTHENIA, 

In  spite  of  the  divergence  of  opinion  among 
these  different  authors,  it  stands  out  clearly  from 
the  sum-total  of  their  observations,  that  in  prac- 
tice one  must  expect  to  meet  among  neuras- 
thenics : 

1.  Dyspeptic  conditions  corresponding  to  the 
slight    or  the   severe    form   of   gastro-intestinal 
atony,  and  in  which  the  secretion  of  hydrochloric 
acid  is  either  normal  or  perceptibly  diminished. 
In  these  cases  the  motor  functions  are  frequently 
affected,  but  most  often  in  a  feeble  degree  only, 
and  it  is  rare  for  them  to  result  in  stasis  with  great 
permanent  dilatation,  such  as  M.   Bouchard  has 
described. 

These  are  the  forms  most  frequently  observed 
in  neurasthenics. 

2.  Dyspeptic  conditions  in  which  hypersecre- 
tion  and  an  increase  of  hydrochloric  acid  are  the 
dominating  features.     Now,  the  exaggerated  se- 
cretion of  hydrochloric  acid  may,  as  is  well  known, 
show  itself  under  three  principal  aspects :   a.  a 
simple  exaggeration  of  the  normal  secretion  at  the 
time  of  digestion ;  b.  permanent  continuous  hy- 
persecretion  of  hydrochloric  acid ;  c.  intermittent 
attacks  of  hypersecretion.     The  last  two  modes 
constitute  the  two  forms  of  Reichmann's  disease. 
Let  us  briefly  recall  the  clinical  characters  proper 
to  each  of  these  types  of  dyspepsia. 

Simple  increase  of  hydrochloric  acid  (simple 
hyperchlorhydria) . — The  general  condition  is  satis- 


LEADING  SYMPTOMS.  65 

factory.  The  appetite  is  usually  preserved,  and 
sometimes  even  exaggerated.  Meals  provoke  gas- 
tric crises  which  appear,  not  immediately  after  the 
ingestion  of  food,  but  at  the  end  of  two,  three  or 
four  hours,  this  being  the  characteristic  feature  of 
this  form. 

The  attack  ordinarily  begins  with  a  feeling  of 
heat  and  burning  localised  at  the  epigastrium. 
Then  come  bitter  and  acid  regurgitations,  which 
cause  a  disagreeable  sensation  in  the  mucous 
lining  of  the  oesophagus,  and  produce  that  peculiar 
pain  behind  the  sternum  which  constitutes  pyrosis. 
This  may  be  all,  but  sometimes  to  these  first  feel- 
ings of  malaise  is  added  a  dry  state  of  the  buccal 
mucous  membrane,  accompanied  by  a  keen  thirst. 
Soon  the  patient  complains  of  more  distressing 
sensations,  of  pains  that  are  sometimes  shooting 
but  more  often  constricting,  and  of  "  cramps  "  that 
radiate  towards  the  hypochondriac  regions  and 
the  back  of  the  thorax,  and  in  the  lower  intercostal 
spaces.  Vomiting  is  absent. 

The  crisis  is  more  or  less  painful,  and  of  variable 
duration  ;  it  does  not  come  on  inevitably  after 
every  meal,  and  it  is  after  the  mid-day  meal  that 
it  appears  most  often  and  is  most  marked.  The 
majority  of  patients  have  only  one  attack,  that  of 
the  afternoon.  Another  important  character  of 
the  attack  of  pain  is  that  it  is  relieved,  or  even 
cured,  by  the  ingestion  of  food  rich  in  albuminoid 
substances,  such  as  milk  or  white  of  egg. 

Neurasthenia  5 


66  NEURASTHENIA. 

This  acid  dyspepsia  is  observed  more  especially 
in  hereditary  neurasthenics,  in  the  descendants  of 
gouty  ancestors,  or  in  those  who  have  themselves 
exhibited  symptoms  of  clearly  arthritic  nature ; 
these  patients  are  capable  of  a  certain  amount  of 
physical  activity,  and  do  not  usually  belong  to  the 
category  of  neurasthenics  with  marked  cerebral 
depression. 

Intermittent  form  of  hypersecretion  of  hydro- 
chloric acid. — The  intermittent  form  of  Reich- 
mann's  disease  is  very  rarely  met  with  in  neuras- 
thenics. It  hardly  ever  appears  except  as  a  passing 
episode,  and  under  the  immediate  influence  of  keen 
mental  anxieties  or  of  intense  emotions  of  a  de- 
pressing character.  In  these  circumstances  it 
occurs  as  a  momentary  complication  of  simple  hy- 
persecretion of  hydrochloric  acid.  Its  essential 
features  are  the  following.  The  attacks  are  more 
or  less  frequent,  being  separated  by  intervals 
whose  duration  varies  from  a  few  days  to  several 
months.  They  last  one  or  two  days,  sometimes 
longer.  The  crisis  ordinarily  begins  in  the  morning 
before  the  first  meal ;  the  patient  experiences  a 
feeling  of  burning  at  the  epigastrium  ;  he  has 
nausea,  and  vomits  some  mouthfuls  of  an  acid 
liquid,  which  is  colourless  or  greyish  or  slightly 
tinted  by  bile,  which  contains  pepsine  and  hydro- 
chloric acid,  and  which  actively  digests  a  piece  of 
boiled  egg  in  vitro.  The  vomitings  of  fluid  from  the 
stomach  are  repeated,  and  are  at  first  abundant, 


LEADING  SYMPTOMS.  67 

but  afterwards  less  copious  in  accordance  with 
the  amount  of  gastric  hypersecretion  ;  the 
ingestion  of  liquids  provokes  them  ;  the  stomach 
is  intolerant ;  the  pains  are  rarely  intense,  but  the 
thirst  is  keen  and  the  anorexia  absolute.  The 
abdomen  is  retracted  rather  than  distended.  The 
patient,  overwhelmed  by  his  exertions  in  vomiting, 
shows  a  pale  face  with  drawn  features ;  his  pros- 
tration is  great,  however  short  a  time  the  crisis 
may  have  lasted.  The  attack  ends  either  abruptly 
or  gradually. 

Continuous  Hypersecretion. — In  this  especially 
severe  form  there  are  absolutely  no  periods  of 
complete  intermission.  It  fairly  often  follows  on 
one  of  the  preceding  forms.  In  these  cases  we 
find  patients  who  for  several  years  have  suffered 
from  the  stomach,  and  whose  dyspeptic  troubles 
have  often  preceded  the  appearance  of  the  first 
symptoms  of  nervous  exhaustion.  Interrupted  at 
first  by  longer  or  shorter  periods  of  improvement, 
the  digestive  disorders  eventually  become  per- 
manent, the  patient's  strength  declines,  he  grows 
thin,  and  when  the  disease  has  reached  its  height 
his  aspect  is  quite  like  that  of  a  person  suffering 
from  cancer  of  the  stomach. 

The  appetite  is  maintained,  but  the  patient  eats 
little  in  order  not  to  arouse  his  pains  ;  in  the  morn- 
ing he  does  not  suffer,  but  three  or  four  hours 
after  the  mid-day  meal  the  first  crisis  of  pain 
comes  on,  accompanied  by  eructations  and  acid 


68  NEURASTHENIA. 

regurgitations.  This  crisis  lasts  one  or  two  hours, 
till  the  vomiting  of  acid  fluid  from  the  stomach 
comes  and  puts  an  end  to  it.  A  second  attack, 
similar  to  the  first,  and  often  more  violent,  occurs 
after  the  evening  meal,  towards  the  middle  of  the 
night.  The  liquid  brought  up  is  for  the  most  part 
composed  of  gastric  juice ;  it  contains  pepsine  and 
hydrochloric  acid.  This  permanent  hypersecretion 
is  accompanied  by  stasis  of  the  food  and  permanent 
dilatation  of  the  stomach.  Thus  it  can  be  observed 
with  the  aid  of  the  stomach-tube  that,  in  the  morn- 
ing before  breakfast,  the  organ  still  contains 
abundant  remnants  of  food,  and  the  liquid  drawn 
off  after  a  test  meal  shows  an  increased  proportion 
of  free  hydrochloric  acid. 

Such  are  the  different  dyspeptic  states  that  may 
be  met  with  in  patients  suffering  from  nervous 
exhaustion.  Must  all  these  forms  of  indigestion 
be  considered  as  really  belonging  to  neurasthenia, 
as  proceeding  from  the  intimate  disorder  of  the 
nervous  centres  on  which  the  manifestations  of 
this  neurosis  depend  ?  Must  it  be  thought,  as 
some  authors  hold,  that  neurasthenia  itself  has 
often  its  origin,  its  first  cause,  in  the  pathological 
condition  of  the  stomach  ?  That  is  a  question  that 
we  shall  discuss  later  in  the  chapter  on  Etiology. 
What  is  at  present  desirable  to  remember  of  this 
rapid  outline  of  the  forms  assumed  by  the  digestive 
disorders  of  neurasthenics,  is  the  very  fact  of 
their  diversity,  and  in  consequence  the  necessity 


LEADING  SYMPTOMS.  69 

that  is  imposed  on  a  medical  man  brought  into 
the  presence  of  a  neurasthenic  suffering  from 
dyspepsia,  of  noting  the  characters  of  that 
dyspepsia  with  precision  and  care.  He  will 
thus  be  in  a  position  to  regulate  judiciously  the 
dietetic  treatment  of  his  patient. 

/.  Cerebral  depression  (mental  state). — Neu- 
rasthenia, being  a  general  disease  of  the  nervous 
centres,  not  only  deranges  the  somatic  functions, 
but  also  disorders  the  psychical.  Whatever  be 
the  clinical  form  that  it  assumes,  a  peculiar  mental 
state  always  accompanies  it,  and  even  constitutes 
a  symptom  of  the  first  rank.  It  often  dominates 
the  clinical  picture,  and  dependent  on  it  is  a  crowd 
of  manifestations  which  seem  at  the  first  glance 
to  be  altogether  unconnected  with  it.  We  cannot 
present  here  a  complete  methodical  study  of  the 
mental  symptoms  of  neurasthenia ;  we  shall  only 
indicate  their  principal  features,  and  show  the 
account  to  which  they  may  be  turned  from  the 
point  of  view  of  the  moral  treatment  suitable  to 
this  class  of  subjects. 

These  mental  disorders  may  be  arranged  in  two 
groups,  comprising,  first,  the  stable  and  permanent 
psychical  modifications,  which  constitute  the  very 
foundation  of  the  psychical  state  of  the  patients ; 
and  secondly,  the  passing  and  incidental  disorders, 
which  are  only  in  some  sort  accidental  complications 
In  general  terms,  there  is  a  conscious  weaken- 
ing of  the  personality,  with  a  more  or  less  pro- 


70  NEURASTHENIA. 

nounced  loss  of  power  in  all  the  faculties,  to  which 
are  incidentally  added  fixed  ideas  and  obsessions. 

Aboulia,  or  enfeeblement  of  the  will,  is  one  of 
the  commonest  features  of  the  mental  state  of 
neurasthenics.  The  consequences  of  this  psychical 
disorder  are  many  :  in  the  intellectual  sphere  it 
brings  on  loss  of,  or  diminution  in,  the  power  of 
attention;  the  patients  are  usually  incapable  of 
thinking  out  a  subject,  of  co-ordinating  their  ideas 
with  precision,  and  of  directing  the  course  of 
them.  Their  thoughts  attach  themselves  to  second- 
ary points,  to  futile  details  ;  they  sometimes  read 
whole  pages  without  having  understood  what  they 
have  read.  When  they  have  applied  themselves 
for  some  instants  to  a  slightly  complicated  intel- 
lectual work,  they  all  at  once  become  confused  ; 
their  feeble  power  of  attention  is  eclipsed  as  if 
it  were  suddenly  exhausted.  Thus  they  are  seen 
to  break  off  suddenly  in  the  course  of  a  conversa- 
tion, and  declare  they  have  forgotten  what  they 
wished  to  say,  and  that  their  heads  feel  empty  and 
without  ideas.  The  decay  of  their  will  shows  itself 
again  by  doubts,  by  interminable  hesitations; 
nothing  is  more  distressing  to  them  than  to  come 
to  a  decision.  It  is  often  on  the  enfeeblement  of 
the  will  that  the  motor  asthenia  depends,  still 
more  than  on  a  special  debility  of  the  muscles. 

The  memory  also  is  diminished  in  these  patients. 
Their  power  of  recalling  past  events  is  defec- 
tive, because  they  are  unable  to  sustain  the 


LEADING  SYMPTOMS.  71 

effort  of  attention  necessitated  by  the  search  for 
the  forgotten  incident,  and  because  the  greater 
part  of  the  events  that  have  taken  place  after  the 
onset  of  their  malady  have  been  perceived  by  them 
feebly,  and  hence  are  badly  associated  with  their 
conscious  personality.  Often  beset  by  some  fixed 
idea,  some  hypochondriacal  preoccupation,  they 
live,  so  to  speak,  in  a  state  of  perpetual  absent- 
mindedness  ;  this  is  one  of  the  causes  that  make 
them  perceive  in  a  vague  and  uncertain  manner 
the  incidents  of  which  they  are  witnesses.  Thus 
they  are  unable  to  recall  them  to  their  memory 
even  when  they  are  still  recent.  Their  acts  of 
forgetfulness,  then,  are  frequent ;  they  are  con- 
nected with  the  most  diverse  subjects,  and  in  fact 
the  amnesia  of  neurasthenics  is  indiscriminate. 
Their  emotionalism  is  extreme;  everything 
impresses  them,  and  every  emotion  is  especially 
distressing  to  them  because  they  perceive  with  un- 
usual vividness  the  diverse  sensations  produced 
in  their  different  systems  (heart,  respiratory 
system,  intestines,  etc.)  by  all  emotional  states. 
Consequently  they  are  seen  to  avoid  with  care 
everything  that  might  agitate  them.  They  are 
timid  and  fearful,  and  have  lost  confidence  in  them- 
selves. The  presence  of  a  stranger  among  those 
habitually  round  them  is  enough  to  put  them  out 
of  countenance  ;  to  address  any  one,  or  to  enter 
into  conversation,  involves  an  effort  that  many  of 
them  shrink  from.  They  neglect  their  social 


72  NEURASTHENIA. 

duties,  deliberately  retire  into  solitude,  and  declare 
themselves  unable  to  manage  their  affairs. 

The  sufferers  are  perfectly  conscious  of  their 
moral  deficiencies.  The  more  courageous  complain 
bitterly  of  them,  and  deplore,  without  being  able  to 
overcome,  the  weakness  of  their  will,  their  memory, 
and  their  intellectual  faculties.  They  try  their 
hand  at  occupations  and  at  subjects  of  study  that 
seem  to  them  likely  to  excite  their  interest  and 
arouse  their  activity ;  but  they  find  the  attraction  of 
novelty  ephemeral.  They  tire  quickly,  are  seized 
with  distaste  for  their  undertaking,  and  soon 
abandon  it  to  pass  to  other  subjects. 

It  results  from  this  weakening  of  the  personality, 
from  this  loosening  of  the  bonds  that  render  stable 
the  synthesis  of  the  ego,  that  these  patients  are 
powerless  to  resist  the  invasion  of  certain  ideas  that 
obtrude  themselves  upon  their  minds  and  hold  for 
the  moment  an  undivided  empire  over  them.  They 
are  suggestionable,  and  consequently  subject  to  all 
sorts  of  fears  and  obsessions,  which  come  some- 
times from  themselves,  and  sometimes  from  the 
circumstances  in  which  they  happen  to  be  placed. 
Their  constant  disorders  of  common  sensation, 
their  feelings  of  malaise,  their  digestive  and  cir- 
culatory derangements,  the  lassitude  that  over- 
whelms them,  all  these  unite  with  their  very 
distinct  feeling  of  mental  impotence  to  keep  up  a 
state  of  depression,  and  to  suggest  a  crowd  of  hypo- 
chondriacal  anxieties. 


LEADING  SYMPTOMS.  73 

Hypochondriasis  is  rarely  absent  in  the  case  of 
patients  attacked  by  nervous  exhaustion,  but  it  is 
not  so  tenacious,  so  unconscious,  nor  so  sys- 
tematised  as  insane  hypochondriasis.  A  neuras- 
thenic who  suffers  more  especially  from  rachialgia 
will  believe  himself  to  be  affected  by  disease  of  the 
spinal  cord;  this  idea  will  torment  and  agitate  him 
— but  his  conviction  is  not  firmly  established ;  he 
only  asks  to  be  reassured,  and  a  few  authoritative 
words  will  be  enough  to  deliver  him  from  his 
fear.  This  same  patient  may  again,  some  days 
later,  believe  that  he  is  attacked  by  disease 
of  the  heart  or  of  the  stomach,  but  his  erroneous 
beliefs  will  never  present  the  characters  of  a  fixed 
idea,  a  systematic  delusion.  However,  the  hypo- 
chondriacal  ideas  that  a  particular  symptom  may 
cause  to  spring  up  in  the  minds  of  these  patients, 
are  not  always  so  transient.  There  are  some  that 
come  to  stay,  so  to  speak,  and  their  continuance 
sometimes  involves  serious  inconveniences.  We 
have  seen  neurasthenic  women,  who,  without 
being  in  any  way  paralysed,  believed  themselves 
absolutely  unable  to  walk  or  to  stand  upright,  and 
ended  by  never  leaving  their  beds,  thus  condemn- 
ing themselves  for  whole  years  to  a  deplorable 
immobility.  It  is,  again,  their  mental  enfeeblement 
and  their  suggestibility  that  give  rise  in  many 
neurasthenics  to  those  intermittent  obsessions, 
those  systematic  fears,  those  phobias,  those  states 
of  passing  anxiety,  that  make  so  vivid  an  im- 


74  NEURASTHENIA. 

pression  on  them  :  agoraphobia,  claustrophobia  or 
fear  of  narrow  and  closed  spaces,  anthropophobia 
or  fear  of  crowds  and  assemblies,  stasophobia 
(Bouveret)  or  fear  of  the  upright  position,  etc., 
are  the  commonest  forms.  All  these  states  of 
anxiety  present  identical  characters  ;  every  time 
that  the  patient  happens  to  be  placed  in  circum- 
stances apt  to  arouse  them,  the  emotional  distress 
is  produced  with  an  irresistible  automatic  force. 

The  suggestibility  of  neurasthenics  again 
explains  the  influence  exerted  on  their  mental 
condition  by  the  surroundings  in  which  they  live. 
Nothing  is  more  adapted  to  foment  or  keep  up 
their  moral  depression  and  hypochondriacal  anxie- 
ties than  the  assiduous  cares,  the  incessantly  re- 
newed inquiries  as  to  their  state  of  health,  and 
the  recommendations  that  are  showered  on  them 
by  their  friends. 

From  this  we  may  gather  the  nature  of  the 
moral  treatment  suited  to  these  patients,  and  the 
beneficial  action  that  may  justly  be  expected  from 
it.  These  neurasthenics  are  not  always  hypnotis- 
able,  but  they  are  suggestible;  hence  it  is  by 
adroit  encouragement,  by  a  cheering  and  sustained 
suggestive  action,  that  the  physician,  when  he  is 
able  to  preserve  his  authority  with  them  and  re- 
tain their  confidence,  can  combat  their  cerebral 
depression  successfully,  and  thus  aid  powerfully  in 
their  cure. 


CHAPTER  III. 
SECONDARY  SYMPTOMS. 

In  addition  to  the  cardinal  symptoms  or  stigmata 
of  neurasthenia  that  we  have  just  passed  in  review, 
there  are  to  be  observed,  in  the  majority  of  cases, 
functional  disorders  of  secondary  rank ;  these 
constitute  in  a  way  the  minor  symptoms  of  the 
neurosis,  but  it  occasionally  happens  that  some  of 
them  take  on  an  unusual  development,  and  impress 
on  the  disease  a  peculiar  clinical  physiognomy. 

a.  Vertigo. — Vertigo  is  a  frequent  symptom  in 
neurasthenia.  The  attacks  are  generally  short. 
As  it  very  often  coincides  with  digestive  disorders, 
many  clinicians  have  supposed  that  it  is  always  of 
gastric  origin.  This  is  doubtless  an  erroneous  in- 
terpretation, and  Beard  and  Charcot  have  rightly 
protested  against  it.  It  is  certain  that  the  attacks 
of  vertigo  sometimes  show  themselves  peculiarly 
intense  in  neurasthenics  who  present  no  disorder 
of  the  digestive  functions ;  and  in  the  second  place 
it  has  been  remarked  that  the  gravest  organic 
gastropathies  are  hardly  at  all  complicated  by 
giddiness.  It  seems  very  probable,  then,  that  the 
greater  part  of  the  attacks  of  vertigo  that  appear 


76  NEURASTHENIA. 

in  neurasthenics  have  a  central  origin,  and  depend 
directly  on  the  disorder  of  the  nervous  centres. 

These  attacks  of  vertigo  occur  sometimes  before 
the  patient  has  broken  his  fast,  sometimes  after 
meals  ;  it  is  especially  in  the  middle  of  the  discom- 
forts of  the  dyspeptic  crisis  that  the  symptom 
manifests  itself.  The  intensity  of  the  attack  is 
extremely  variable ;  sometimes  there  is  nothing 
beyond  a  rapid  sensation  of  loss  of  balance,  or 
movement  of  the  ground,  but  the  attack  may  be 
more  violent ;  the  patient  feels  as  if  pushed  in 
different  directions,  the  ground  seems  to  rise 
and  fall  under  him  alternately,  and  he  staggers 
like  a  drunken  man,  and  has  to  cling  to  neighbour- 
ing objects  to  prevent  himself  from  falling.  The 
features  of  the  crisis  are  sometimes  identical  with 
those  observed  in  Meniere's  vertigo  ;  in  such  cases 
the  patient  notices  a  humming  or  a  shrill  whistling 
at  the  onset  of  the  attack,  then  he  has  a  sensation 
of  falling  forwards,  of  being  precipitated  into  a 
gulf,  but  the  impulse  is  never  so  violent  as  in 
Meniere's  disease,  and  does  not  go  so  far  as  to 
make  him  fall  to  the  ground.  This  form  of  neu- 
rasthenic vertigo  is  frequently  accompanied  by 
nausea  and  vomiting ;  it  disappears  after  lasting 
for  a  few  minutes,  but  leaves  the  patient  in  a 
most  distressing  state  of  dejection  and  agitation. 
Rotatory  vertigo  is  rarely  observed. 

Finally,  in  certain  cases,  rare  it  is  true,  the 
giddiness  of  neurasthenics  is  almost  continuous. 


SECONDARY  SYMPTOMS.  77 

The  clinical  picture  is  then  very  similar  to  that 
presented  by  patients  suffering  from  cerebellar 
vertigo. 

b.  Motor  disorders. — We  have  already,  in 
studying  the  stigmata  of  the  neurosis,  described 
the  enfeeblement  of  the  neuro-muscular  system  ; 
a  certain  number  of  other  motor  disorders  are 
also  to  be  observed  in  neurasthenics,  namely  mus- 
cular cramps,  fibrillar  contractions  similar  to 
those  seen  in  persons  attacked  by  progressive 
muscular  atrophy  of  spinal  origin,  and  functional 
contractures  such  as  writer's  cramp.1 

Trembling  has  been  noted  in  nervous  exhaustion 
by  Beard  and  by  M.  Pitres ;  it  is  usually  limited 
to  the  upper  limbs,  and  is  a  fine  trembling  with 
short  rapid  oscillations  like  those  of  the  trembling 
of  exophthalmic  goitre. 

Paralyses. — Are  true  motor  paralyses  to  be  met 
with  in  the  course  of  neurasthenia  ?  We  believe, 
as  do  others,  and  notably  Ziemssen,  that  such  par- 
alyses do  not  form  part  of  the  clinical  picture  of 
pure  neurasthenia.  Beard,  however,  observed 
attacks  of  paralyses  or  of  paresis  in  some  of  his 
patients.  M.  Bouveret  has  noticed  incomplete 
paralysis  of  very  short  duration,  limited  either  to 
one  limb  or  to  the  two  lower  limbs,  and  "  occurring 
in  attacks  that  lasted  a  few  minutes  only."  We 
have  never  met  with  cases  of  this  class,  and  we 
believe  that  the  majority  of  them  are  usually  com- 

iThere  is  usually  a  slight,  but  real,  impairment  of  co-ordination. 
— Trans. 


78  NEURASTHENIA. 

plicated  by  hysteria.  If  these  motor  paralyses 
really  do  exist  in  pure  neurasthenia,  they  are  cer- 
tainly of  extreme  rarity. 

c.  Disorders  of  common  sensation. — Perver- 
sions of  common  sensation  often  occur  in  neuras- 
thenics, and  the  most  frequent  of  all  is  assuredly 
hyper&sthesia.  We  have  already  mentioned  per- 
sistent headache,  painful  sensibility  of  the  scalp, 
and  rachialgia  in  its  diverse  forms.  These  are  the 
most  habitual  localisations  of  the  hyperaesthesia, 
but  any  part  may  be  affected.  Hyperaesthetic 
zones,  even  pains  of  neuralgic  type,  prickings, 
shooting  sensations  recalling  the  lightning  pains 
of  locomotor  ataxia.  and  feelings  of  burning, 
appear  and  disappear  turn  by  turn  in  the  length  of 
the  limbs,  in  the  thorax,  and  in  the  abdomen 
(general  neuralgia  of  Valleix). 

Sometimes  the  morbid  condition  of  common 
sensation  displays  itself  by  an  exquisite  sensitive- 
ness to  heat  and  above  all  to  cold.  Many  patients 
complain  constantly  of  being  cold  ;  they  overload 
themselves  with  clothes  even  in  the  warm  season. 
They  are,  moreover,  strongly  affected  by  external 
influences,  such  as  atmospheric  changes,  wind, 
humidity,  storms.  Of  some  of  them  it  has  been 
said  with  reason  that  they  are  veritable  living 
barometers. 

The  disorders  of  sensation  are  also  manifested 
in  the  form  of  parczsthesicz.  The  patients  fre- 
quently experience  feelings  of  numbness  in  the 


SECONDARY  SYMPTOMS.  79 

limbs ;  it  seems  to  them  that  some  segment  or 
other  of  a  limb  is  "  as  if  dead,"  or  "  wooden,"  or 
"  strangely  light,"  or  else  as  heavy  as  lead.  Per- 
haps neuro-muscular  asthenia  is  in  these  patients 
only  the  consequence  of  a  feeling  of  permanent 
fatigue,  or,  if  the  expression  be  preferred,  of  a 
peculiar  dysaesthesia  of  the  locomotor  system. 
Ancssthesia,  in  the  strict  sense  of  the  word,  does 
not  exist  in  pure  neurasthenic  states,  that  is  in 
states  without  admixture  of  hysteria.  If  the 
seats  of  these  various  perversions  of  sensation 
are  explored  methodically,  they  are  never 
found  to  be  anaesthetic. 

But,  independently  of  the  disorders  of  super- 
ficial sensibility  which  affect  the  teguments,  neur- 
asthenics exhibit  perversions  of  the  sensibility 
of  deep  organs  which  are  vague  and  ill-defined, 
but  none  the  less  very  real  and  very  important. 
Those  who  live  in  a  state  of  perfect  health  never 
perceive  the  regular  play  of  their  organs  ;  it  is 
not  the  same  with  neurasthenics,  who  are  con- 
stantly affected  by  the  most  diverse  internal  sen- 
sations. The  movements  of  the  heart  and  the 
arteries,  the  work  of  digestion,  locomotion,  intel- 
lectual effort,  the  complex  play  of  emotional  states, 
all  the  functions  of  organic  life  and  the  life  of 
relation,1  give  rise  in  them  to  vague  and  change- 
able, but  always  distressing,  impressions.  That 

!The  life  of  relation  comprises  the  functions  subserved  by  the 
sense  organs,  the  nervous  system,  and  the  voluntary  muscles ;  the 
systems,  that  is,  that  bring  a  being  possessing  them  into  more 
immediate  relation  with  the  outer  world. — Trans. 


80  NEURASTHENIA. 

is  to  say  their  common  sensation  is  profoundly 
disordered.  They  feel  quite  strange,  quite 
changed.  Thence  comes  that  indefinable  feeling 
of  being  out  of  sorts,  of  which  the  greater  number 
of  these  patients  complain  ;  thence  also  without 
doubt  comes,  as  we  shall  see  later  in  studying 
their  mental  state,  their  tendency  to  hypochondria 
and  melancholy. 

d.  Disorders  of  the  circulation. — Disorders  of 
the  circulation  occur  in  all  neurasthenics,  affect- 
ing sometimes  the  heart  and  sometimes  the  peri- 
pheral vessels.  The  derangements  of  the  cardiac 
innervation  assert  themselves  occasionally  with 
such  intensity  that  they  mask  in  some  sort  all  the 
other  symptoms  of  nervous  exhaustion.  It  is 
cases  of  this  class  that  have  led  some  authors  to 
describe  a  cardiac  form  of  neurasthenia.  Though 
less  obtrusive,  the  disorders  of  the  peripheral 
circulation  are  none  the  less  very  frequent  and 
very  real.  It  is,  in  fact,  to  alternations  of  spasm 
and  dilatation  of  the  arteries  and  veins,  that  are 
due  the  anaemia  and  the  passing  congestions  of 
the  skin  and  mucous  membranes  commonly  ob- 
served in  these  patients  ;  and  some  authors  have 
thought  that  it  is  possible  to  explain  solely  by  the 
derangement  of  vaso-motor  innervation  the 
different  symptoms  that  figure  in  the  clinical  pic- 
ture of  neurasthenia.1  We  shall  return  later  to 

!The  pseudo-anaemia  is  not  always  transient.  It  is  presumably 
accompanied  by  congestion  in  the  splanchnic  area,  and  to  the  super- 
ficial anaemia  and  deep  congestion  may  be  due  some  of  the  paraes- 
thesiae  observed. — Trans. 


SECONDARY  SYMPTOMS.  81 

this  vaso-motor  theory  of  nervous  exhaustion, 
which  was  propounded  by  Anjel. 

Disorders  of  the  heart. — Palpitations. — It  is  in 
the  form  of  these  last  that  the  disordered  cardiac 
innervation  shows  itself.  The  palpitation  of  neur- 
asthenics occurs  in  attacks  of  varying  duration 
and  intensity.  These  attacks  have  no  gravity ;  but 
they  return  frequently,  and  their  reappearances 
occur  under  the  influence  of  the  most  diverse  and 
often  the  most  futile  causes:  a  slight  emotion, 
even  a  moderate  physical  effort,  or  the  work  of 
digestion,  suffices  to  provoke  them.  These  palpi- 
tations, and  the  distressing  sensations  by  which 
they  are  accompanied,  disturb  the  minds  of  the 
patients,  who  soon  believe  themselves  to  be 
affected  with  some  grave  lesion  of  the  heart. 

Tachycardia. — The  disorder  of  cardiac  innerva- 
tion may  be  more  profound  and  more  stable,  and 
may  manifest  itself  under  the  form  of  permanent 
acceleration  of  the  rhythm  of  the  heart.  This 
tachycardia  of  neurasthenics  exactly  resembles 
that  seen  in  exophthalmic  goitre :  the  number  of 
pulsations  may  rise  to  120,  130,  or  even  more; 
the  beatings  of  the  heart  seem  energetic ;  the 
patient  perceives  them  distinctly,  and  the  ob- 
server's hand,  placed  on  the  precordial  region, 
feels  a  very  marked  impulse  at  each  beat.  The 
pulsations  of  the  carotids  are  exaggerated,  but  the 
radial  pulse  on  the  contrary  is  small  and  feeble.1 

1  Visible  beating  of  superficial  arteries  is  not  infrequently  seen  in 
neurasthenia  apart  from  any  tachycardia,  and  probably  apart  also 
from  arterio-sclerosis ;  and  epigastric  pulsation  is  common. — Trans. 

Neurasthenia  6 


82  NEURASTHENIA. 

It  is  usually  regular;  but  in  certain  cases  the 
pulsations  are  found  to  be  irregular  in  both  force 
and  rate.  Want  of  rhythm,  however,  has  not  here 
the  grave  significance  that  it  possesses  in  organic 
diseases  of  the  heart.  This  chronic  tachycardia 
may  last  for  months  together ;  it  passes  succes- 
sively through  phases  of  aggravation  and  of  re- 
mission, but  ends  by  disappearing  either  spon- 
taneously or  under  the  influence  of  general  treat- 
ment directed  against  the  neurasthenic  condition. 
M.  Bouveret  however  holds  that  the  tachycardia 
with  which  we  are  dealing  here  may  present 
itself  in  a  serious  form  ending  in  enfeeblement  of 
the  myocardium,  dilatation  of  the  cavities  of  the 
heart,  and  death  from  asystole.  The  existence 
of  such  a  form  still  rests  on  too  small  a  number 
of  cases  to  be  admitted  without  opposition.  It  is 
in  any  case  extremely  rare. 

Neurasthenic  tachycardia  is  habitually  observed 
in  those  cases  of  nervous  exhaustion  in  which  the 
cerebral  depression  is  profound,  and  in  which 
intense  or  persistent  digestive  disorders  have 
brought  on  general  enfeeblement  and  wasting. 

Slowing  of  the  movements  of  the  heart. — 
There  are,  again,  other  disorders  of  the  functions 
of  the  heart  that  are  exhibited  by  neurasthenics. 
Slowing  of  the  pulse  has  been  noted :  the 
number  of  beats  may  fall  to  50  a  minute.  This 
slowing  of  the  heart  is  sometimes  accompanied 
by  irregularity ;  in  such  a  case  the  pulse  is  usually 


SECONDARY  SYMPTOMS.  83 

small  and  compressible.  Such  a  state  of  persist- 
ent slowness  with  lowering  of  the  arterial  tension 
follows  most  often  on  periods  of  cardiac  excite- 
ment ;  it  is  rarely  primary,  and  an  excitement, 
however  slight,  or  an  emotion  is  usually  enough  to 
put  an  end  to  the  habitual  slowness  of  the  pulse 
and  to  accelerate  for  the  moment  the  beatings  of 
the  heart.  Thus  one  again  finds  in  the  state  of 
the  cardiac  functions  that  feebleness  and  irritability 
which  are  the  characteristics  of  functional  dis- 
orders of  neurasthenic  origin. 

Angina  pectoris. — This  distressing  symptom 
sometimes  shows  itself  in  neurasthenics.  But  the 
angor  pectoris  of  neurasthenia,  like  that  of  hysteria, 
belongs  to  the  group  of  benignant  anginas.  It  is 
none  the  less  a  source  of  terror  and  anxiety  for 
the  persons  attacked  by  it,  and  is  peculiarly  apt 
to  throw  them  into  a  state  of  extreme  dejection 
and  depression.  It  almost  always  assumes  the 
vaso-motor  form. 

The  patient  suddenly  experiences  in  the  pre- 
cordial  region  a  feeling  as  of  being  gripped,  a  sen- 
sation of  constriction,  which  quickly  becomes  ex- 
tremely painful,  and  radiates  immediately  into  the 
left  shoulder  and  arm,  sometimes  even  into  the 
lower  limb  of  the  same  side.  He  is  a  prey  to 
anguish,  to  inexpressible  terror.  His  breathing  is 
short  and  quick  ;  his  face  pale  and  livid  ;  his  ex- 
tremities also  are  pale,  cold,  and  apparently  blood- 
less. The  pulse  is  small  and  feeble,  and  the  heart- 


84  NEURASTHENIA. 

beats  are  almost  imperceptible.  This  phase  of  the 
attack  probably  corresponds  to  a  state  of  spasm  of 
the  peripheral  arteries  and  perhaps  of  the  arteries 
of  the  heart. 

After  a  duration  often  sufficiently  long  (some 
minutes,  a  quarter  of  an  hour  on  the  average), 
the  crisis  terminates  by  an  evident  change  in  the 
state  of  the  circulation.  The  face  becomes  red 
and  hot ;  the  energy  of  the  heart-beats  increases, 
their  rhythm  is  first  hastened,  then  slowed,  and 
everything  returns  into  order. 

Disorders  of  the  peripheral  circulation. — Dis- 
ordered innervation  of  the  arteries  and  veins 
manifests  itself  by  alternations  of  constriction 
and  dilatation  of  these  vessels.  These  changes 
are  more  or  less  abrupt;  they  are  sometimes 
transient  and  sometimes  persistent.  Vaso-con- 
strictor  irritability  declares  itself  by  pallor  and 
coldness  of  the  segments  of  the  body,  and  by 
smallness  of  the  pulse.  These  modifications  are 
usually  limited  to  the  extremities  of  the  limbs  and 
to  the  face.  They  appear  and  disappear  under 
the  influence  of  various  causes,  such  as  an 
emotion,  anxiety,  or  a  sensation  of  cold.  When 
the  vascular  spasm  is  general  and  sudden,  it  may 
cause  intense  and  prolonged  shivering,  accom- 
panied by  trembling  and  a  considerable  fall  of  the 
peripheral  temperature.  The  aspect  of  the  patient 
then  exactly  resembles  that  of  a  sufferer  from 
malaria  in  the  initial  shivering  stage  of  the  attack. 


SECONDARY  SYMPTOMS.  85 

These  vaso-motor  crises,  by  their  intensity  and 
their  sometimes  regular  reappearances,  have  oc- 
casionally led  physicians  astray,  and  made  them 
believe,  in  the  absence  of  direct  verification,  that 
true  febrile  attacks  were  present. 

The  phenomena  of  vaso-dilatation  are  not  less 
common.  Moreover  they  frequently  alternate 
with  states  of  constriction  of  the  vessels.  Under 
the  influence  of  very  slight  excitations  there  may 
be  seen  to  appear,  in  the  majority  of  neurasthenics, 
blushes  of  redness  disposed  in  patches  or  in 
blotches  more  or  less  extended  over  the  face,  the 
chest,  or  the  extremities.  This  vaso-motor  dis- 
order may  go  so  far  as  to  produce  oedematous  in- 
filtrations which  are  mobile  and  transient,  usually 
symmetrical,  and  limited  to  the  extremities  of  the 
lower  limbs. 

It  has  been  asked — and  the  question  may  prob- 
ably be  answered  in  the  affirmative — if  similar 
modifications  are  not  equally  produced  in  the 
viscera,  provoking,  according  to  the  organ  impli- 
cated, one  or  other  of  the  manifestations  observed 
in  neurasthenics ;  for  example,  attacks  of  diarrhoea 
when  the  intestine  is  affected,  angina  pectoris 
when  the  coronary  arteries  are  affected,  vertigo, 
cerebral  depression,  insomnia,  etc.,  when  the 
brain  centres  are  involved.1 

e.    Disorders  of  the  sense  organs. — Any  of  the 

iAnother  circulatory  symptom  is  exaggeration  of  the  effect  of 
posture  on  the  pulse-rate,  due  to  lessened  vaso-motor  control. — 
Trans. 


86  NEURASTHENIA. 

senses  may  be  affected,  but  more  especially  sight 
and  hearing. 

Sight. — Passing  injection  of  the  conjunctiva  has 
been  described,  accompanied  by  slight  oedema  of 
the  eyelids.  But  the  principal  ocular  disorder 
consists  in  a  quite  special  weakening  of  vision — 
we  refer  to  the  neurasthenic  asthenopia  of  Ameri- 
can authors.  The  eye  tires  quickly.  As  soon  as 
the  patient  takes  to  reading,  or  to  any  other  occu- 
pation requiring  a  sustained  effort  of  sight,  he  ex- 
periences a  painful  feeling  of  tension  in  the  eye- 
balls, soon  followed  by  confusion  of  the  visual 
images  j  however,  the  transparent  media  and  the 
membranes  of  the  eye  are  normal.  The  correction, 
with  the  aid  of  appropriate  glasses,  of  any  disorder 
of  refraction  that  may  exist,  does  not  render  the 
neurasthenic  more  able  to  sustain  a  somewhat 
prolonged  effort  of  vision,  .and  he  is  occasionally 
obliged  to  restrain,  and  even  to  stop,  his  profes- 
sional occupations.  There  is  probably  here  a  state 
of  weakness  of  the  muscles  of  accommodation. 
Neurasthenic  asthenopia  is  often  obstinate ;  it 
may  come  on  in  attacks  of  longer  or  shorter  dura- 
tion, or  it  may  be  continuous ;  it  then  becomes  a 
cause  of  despair  to  the  patients,  and  contributes 
powerfully  to  aggravate  their  cerebral  depression. 

Narrowing  of  the  field  of  vision  has  been  des- 
cribed in  certain  cases  of  pure  neurasthenia 
(Westphal,  Charcot,  Pitres),  but  this  symptom  is 
quite  exceptional,  always  transitory  and  of  very 


SECONDARY  SYMPTOMS.  87 

short  duration.  It  appears  especially  at  the 
moment  of  attacks  of  vertigo. 

Hearing. — The  auditory  apparatus  may  become 
irritable  in  the  same  way  as  the  other  sense- 
organs.  One  may  observe,  especially  in  women, 
an  auditory  hyperaesthesia  that  is  truly  pathologi- 
cal ;  they  perceive  the  slightest  noises,  and  those 
of  the  street  and  the  house  become  insupportable 
to  them  and  cause  them  genuine  torment.  In 
order  to  escape  these  discomforts,  the  patients 
shut  themselves  up  in  their  rooms  and  condemn 
themselves  to  veritable  seclusion,  They  hear  the 
beatings  of  their  arteries  to  such  a  point  as  to  be 
disturbed  thereby  when  falling  asleep. 

Auditory  sensations  are  also  produced  spon- 
taneously, apart  from  any  external  stimulus  ;  the 
patients  complain  of  suddenly  hearing  whistlings, 
hummings,  or  short  sharp  sounds  resembling  de- 
tonations. 

Taste  and  Smell  also  in  some  cases  present 
special  perversions  or  irritability. 

/.  Disorders  of  the  genito-urinary  organs. — 
When  neurasthenia  follows  on  a  lesion  or  a  func- 
tional disturbance  of  the  genital  organs,  it  is 
accompanied  by  a  series  of  disorders  of  the  sexual 
functions,  which,  by  their  predominence  over  the 
other  symptoms,  give  a  peculiar  physiognomy  to 
the  disease.  This  form  of  neurasthenia  will  be 
described  further  on  under  the  name  of  genital 
neurasthenia. 


88  NEURASTHENIA. 

But  apart  from  this  special  form,  genital  and 
urinary  disorders  may  fairly  often  be  observed  in 
cases  of  nervous  exhaustion  proceeding  from  any 
other  cause,  for  instance  from  a  traumatic  shock, 
or  from  intellectual  or  moral  over-pressure.  These 
disorders  are  of  variable  intensity,  and  present  the 
following  symptoms :  the  patients  complain  of 
progressive  diminution  of  the  sexual  appetite, 
which  may  go  as  far  as  impotence,  and  they  are 
subject  to  nocturnal  pollutions.  These  phenomena 
may  be  the  starting-point  of  serious  hypochon- 
driacal  ideas. 

When  discussing  the  etiological  theories  of 
neurasthenia,  we  shall  mention  the  utero-ovarian 
troubles  that  may  be  observed  in  women,  and 
shall  indicate  the  share  taken  by  those  symp- 
toms in  the  development  of  neurasthenia  itself. 

On  the  part  of  the  urinary  functions  one  meets 
with  varied  disorders  :  many  patients  are  tor- 
mented by  frequent  desire  to  micturate,  others 
complain  of  micturating  with  difficulty.  We  shall 
see  how  great  is  the  influence  of  auto-suggestion 
on  the  appearance  and  persistence  of  this  class  of 
troubles. 

Polyuria,  oxaluria,  and  transient  albuminuria 
have  all  been  noted  in  the  course  of  neurasthenic 
conditions.  According  to  Albert  Robin,1  15  per 
cent,  of  neurasthenics  have  phosphaturia,  and  10 
per  cent,  albuminuric  phosphaturia.  In  10  per 

iWritten  communication. 


SECONDARY  SYMPTOMS.  89 

cent,  the  phosphorus  is  incompletely  oxidised, 
and  there  is  phosphoruria.  A  certain  number 
show  an  increase  of  the  organic  salts  eliminated, 
the  increase  amounting  to  from  30  to  50  or  60  per 
cent. ;  but  these  in  all  probability  are  contingent 
or  secondary  phenomena  unconnected  with  the 
fundamental  and  primitive  symptomatology  of  the 
neurosis.1 

i  It  would  be  remarkable  if  so  frequent  a  concomitance  were 
accidental.  Polyuria  is  presumably  one  of  the  vaso-motor  defects, 
and  oxaluria  and  phosphaturia  two  of  the  disorders  of  metabolism 
that  occur  in  those  predisposed  to  neurasthenia.  (See  Introduction). 
Albuminuria  is  not  easy  to  explain ;  Dr.  Dukes  holds  that  albuminuria 
may  sometimes  be  of  vaso-motor  origin,  and  its  not  infrequent 
occurrence  in  healthy  subjects  after  cold  baths  or  violent  exercise 
seems  to  support  this  view. 

Another  occasional  symptom  of  neurasthenia  is  a  slight  degree  of 
paraphasia,  possibly  due  to  enfeeblement  of  attention.  It  has  also 
been  observed  that  the  blood -pressure  in  neurasthenics  is  low,  and 
the  reflexes  (both  tendinous  and  superficial)  exaggerated,  that  their 
respiration  is  often  shallow,  and  that  they  sometimes  suffer  from 
attacks  of  hemicrania.  It  will  be  found,  however,  that  these  latter 
conditions,  though  doubtless  increased  during  the  attack  of  neuras- 
thenia, were  in  most  cases  present  in  the  patient  beforehand ;  they 
are  really  symptomatic  of  the  fundamental  condition  on  which 
neurasthenia  is  usually  developed.  (See  Introduction). — Trans. 


CHAPTER   IV. 
FORMS  OF  NEURASTHENIA. 

The  signs  of  neurasthenia  that  we  have  just 
passed  in  review  may  be  grouped  in  different  ways, 
so  that  the  clinical  physiognomy  of  the  affection 
looked  at  as  a  whole  varies  according  to  the  case. 
The  analytical  study  of  the  disorders  that  con- 
stitute it  does  not  give  a  sufficiently  precise  notion 
of  these  differences  of  aspect,  and  all  authors,  from 
Beard  onwards,  have  felt  the  necessity,  in  order  to 
communicate  to  their  descriptions  more  reality  and 
life,  of  tracing  the  picture  of  the  multiple  forms 
that  the  malady  may  assume. 

Although  the  semeiological  study  that  we  have 
sketched  is  only  a  simple  preface  to  the  setting 
forth  of  the  hygienic  measures  required  for  the 
prophylaxis  and  treatment  of  neurasthenia,  yet  we 
cannot  here  neglect  the  forms  of  the  affection,  for 
some  of  them  at  least  require  special  therapeutical 
treatment  and  particular  rules  of  hygiene. 

Authors  hardly  agree  as  to  the  number  and  the 
varieties  of  these  forms.  It  would  be  superfluous 
to  recall  here  the  different  nomenclatures  that 


FORMS  OF  NEURASTHENIA.         91 

have  been  drawn  up  by  writers  on  neurasthenia; 
we  shall  only  say  that  the  majority  have  multiplied 
them  to  excess. 

Among  those  described  are  some  that  hardly 
deserve  more  than  simple  mention  in  a  work  like 
this.  We  shall  indicate  them  without  lingering 
over  them.  Such  is  the  hereditary  form,  of  early 
onset,  long  duration,  and  tenacious  symptoms. 
Exciting  causes  do  not  seem  indispensable  to  its 
appearance;  it  manifests  itself  about  puberty,  often 
without  appreciable  reason,  in  young  people  with  a 
heavily-laden  morbid  heredity,  and  who  have  some- 
times exhibited  in  childhood  eccentricities  of 
temper,  character,  and  intelligence.  In  these 
patients  the  neurasthenic  stigmata  are  fairly  com- 
monly associated  with  the  stigmata  of  so-called 
degeneration,  scruples,  doubts,  obsessions,  and 
various  impulses. 

Such  again  is  the  acute  form  (nervosisme  aigu  of 
Bouchut)  which,  it  is  said,  develops  suddenly  under 
the  influence  of  a  powerful  exciting  cause,  such  as 
a  violent  moral  or  physical  shock,  is  accompanied 
by  fever,  and  may  end  in  death.  The  observations 
by  which  it  has  been  sought  to  support  the  exist- 
ence of  this  type  are  at  present  few  in  number  and 
not  sufficiently  convincing.  In  fact  nothing,  up  to 
the  present,  authorises  us  to  affirm  that  there  is 
such  a  thing  as  acute  neurasthenia;  but  there  is 
sometimes  an  acute  stage  at  the  onset  of  chronic 
neurasthenic  conditions,  characterised  by  the 


92  NEURASTHENIA. 

sudden  and  rapid  appearance  of  the  different 
signs  of  nervous  asthenia,  which,  after  a  some- 
times short  duration,  grow  better  only  to  reappear 
soon  and  install  themselves  permanently. 

By  the  side  of  the  two  preceding  forms,  which 
are  based  on  the  etiology  and  progress  of  the 
disorders,  many  others  have  been  created  that  are 
founded  on  the  localisation  of  the  symptoms  and 
their  predominance  in  one  part  or  another  of  the 
nervous  system.  Of  this  number  are: — the 
hemi-neurasthenia  described  by  Beard  and 
Charcot  (neurasthenic  dimidiee),  in  which  the  per- 
sistent headache,  the  muscular  feebleness,  and  the 
various  disorders  of  sensation  localise  themselves 
in  one  side  of  the  body,  and  may,  on  a  cursory  exam- 
ination, give  the  illusion  of  organic  hemiparesis  ; 
gastric  neurasthenia,  with  predominance  of  gastro- 
intestinal atony;  cardiac  neurasthenia  (cerebro- 
cardiac  neuropathy  of  Krishaber),  which  manifests 
itself  principally  by  precordial  anxiety,  attacks  of 
false  angina  pectoris,  palpitations,  and  rushes  of 
heat  to  the  face;  neurasthenia  of  neuralgic  form, 
characterised  especially  by  neuralgias  of  varied 
situation;  monosymptomatic  neurasthenia  (Pitres), 
which  shows  itself  by  fixed  and  localised  pains,  in 
the  tongue  (glossodynia),  in  the  breast,  in  the 
coccyx,  or  on  certain  points  of  the  genital  organs 
(clitoris).  These  topoalgias  (P.  Blocq)  are  ordin- 
arily the  starting-point  of  keenly  felt  hypochon- 
driacal  ideas  and  of  obsessions,  which  throw 


FORMS  OF  NEURASTHENIA.         93 

the  painful  phenomenon  itself  into  the  background 
of  the  clinical  picture. 

We  need  not  insist  longer  on  the  preceding  forms, 
and  shall  confine  ourselves  to  presenting  with 
some  degree  of  development  those  that  seem  to 
have  a  more  marked  individuality  and  a  quite  special 
physiognomy. 

These  forms  group  themselves  into  four: 

1.  Cerebro-spinal  neurasthenia  (of  which  cere- 
bral neurasthenia  or  cerebr asthenia,   and   spinal 
neurasthenia     or     myelasthenia     are   only    sub- 
divisions) ; 

2.  Neurasthenia  of  women ; 

3.  Genital  neurasthenia; 

4.  Traumatic  neurasthenia. 

1.  Cerebro-spinal  Neurasthenia. — This  does 
not  require  a  long  descripton ;  for  it  sums  up  in 
itself  the  most  ordinary  symptoms  of  the  affection, 
such  as  we  have  already  described.  It  is,  in 
short,  both  the  commonest  and  the  completest 
form  of  neurasthenia.  In  it  are  found  persistent 
headache,  vertigo,  insomnia,  emotionalism,  in- 
aptitude for  brain  work,  rapid  fatigue  of  vision, 
muscular  feebleness,  rachialgia,  various  neuralgic 
pains,  and  gastro-intestinal  atony,  with  or  with- 
out precordial  anxiety. 

When  it  is  the  cerebral  manifestations  that  pre- 
dominate to  the  exclusion  of  the  spinal,  there  is 
said  to  be  Cerebr  asthenia.  On  the  other  hand, 
where  the  headache  is  slight,  brain  work  still  re- 


94  NEURASTHENIA. 

latively  easy,  and  vertigo  little  marked,  whereas 
pains  in  the  back,  sensations  of  burning  along 
the  vertebral  column,  loss  of  motor  power,  rapid 
fatigue  and  giving  way  of  the  legs,  heaviness  and 
pain  in  the  limbs,  and  digestive  troubles  dominate 
the  clinical  scene,  the  case  is  one  of  Myelasthenia. 

This  is  the  old  spinal  irritability  of  authors. 
There  is  no  need  to  delay  longer  over  it. 

2.  Neurasthenia  of  Women. — This  deserves 
to  be  described  separately,  for  although  it 
borrows,  of  course,  its  constituent  features  from 
the  general  plan  of  neurasthenia,  yet  it  has  a 
special  physiognomy,  and  requires,  as  will  be  seen 
later,  a  special  treatment.  It  has  been  best  ob- 
served and  best  described  by  Weir  Mitchell;  this 
author  has  moreover  formulated  the  rules  of  a 
rational  treatment,  of  which  experience  has  shown 
the  incontestable  efficacy  in  a  large  number  of 
cases. 

Neurasthenia  of  women  represents  a  separate 
type,  which  of  course  is  only  observed  in  women, 
but  which  does  not  comprise  all  cases  of  neur- 
asthenia occurring  in  the  female  sex. 

Its  etiology  is  somewhat  special :  sometimes  it 
is  consecutive  to  painful  disorders  of  the  utero- 
ovarian  apparatus,  but  more  often  it  is  the  result 
of  physical,  intellectual,  or  moral  over-pressure, 
and  among  the  circumstances  that  are  liable  to 
bring  on  this  over-pressure,  there  is  one  that  is 
often  found  at  the  origin  of  the  neurasthenia  of 


FORMS  OF  NEURASTHENIA.         95 

women,  whose  frequency  and  importance  Weir 
Mitchell  has  rightly  brought  to  the  front :  owing 
to  the  regular  and  continued  cares  that  women,  in 
their  quality  of  natural  sick  nurses,  are  often  obliged 
to  lavish  on  those  near  to  them,  on  their  fathers, 
their  husbands,  their  children,  they  fall  into  a  state 
of  physical  exhaustion,  due  directly  to  insufficient 
nourishment,  a  confined  life,  and  insomnia  ;  and  to 
this  is  added  the  distress  caused  by  continued 
anxiety  about  the  result  of  the  illness,  and  some- 
times the  grief  consequent  on  a  fatal  termination. 
Neurasthenia  often  comes  on  at  the  end  of  these 
long  periods  of  torment,  of  apprehension,  of  sor- 
row, of  over-pressure  of  the  whole  being,  and  not 
rarely  it  assumes  sufficiently  special  characters. 

The  dominant  feature  of  this  neurasthenic  state 
is  profound  discouragement,  powerlessness  to 
exert  the  will,  in  one  word  aboulia,  joined  to  a 
degree  of  muscular  asthenia  that  is  hardly  ever 
seen  except  in  this  form.  The  patients  tire  on  the 
slightest  effort,  and  finally  they  no  longer  dare 
walk,  either  because  of  the  extreme  lassitude  they 
feel  when  erect,  or  because  they  suffer  from  con- 
tinual vertigo,  or  because  they  find  the  upright 
position  and  walking  a  source  of  fatigue,  uneasi- 
ness and  distress.  Thenceforward  they  cease  to 
go  out  and  confine  themselves  to  their  room,  where 
they  pass  the  days,  seated  or  more  often  lying,  in 
the  most  complete  idleness.  In  fact,  all  activity 
is  painful  to  them :  they  cannot  read  without  be- 


96  NEURASTHENIA. 

coming  tired,  nor  listen  to  a  conversation  of  any 
length ;  still  less  can  they  write,  sew,  or  apply 
themselves  to  any  other  work.  They  feel  vague 
diffuse  pains,  the  appetite  becomes  languishing, 
the  stools  infrequent  and  difficult ;  sometimes  the 
patients  grow  thin,  but  often  enough  they  keep  up 
their  flesh,  and  often  have  an  illusory  appearance 
of  relatively  good  health. 

The  patient's  friends  usually  intervene  to  aggra- 
vate the  evil,  either  because  they  believe  her 
disease  to  be  "  imaginary,"  and  display  doubts  on 
the  subject  of  her  sufferings  and  incapacity  which 
are  of  a  nature  to  increase  her  worries  and  distress, 
or  on  the  other  hand  because  they  show  her  an  ill- 
regulated  sympathy  that  is  no  less  prejudicial. 
"  There  is,"  says  Weir  Mitchell,  "  one  fatal 
"  addition  to  the  weight  which  tends  to  destroy 
"  women  who  suffer  in  the  way  I  have  described. 
"  It  is  the  self-sacrificing  love  and  over  careful 
"  sympathy  of  a  mother,  a  sister,  or  some  other 
"  devoted  relative.  Nothing  is  more  curious, 
"  nothing  more  sad  and  pitiful,  than  these 
"  partnerships  between  the  sick  and  selfish 

"  and    the     sound    and    over-loving 

"  The  patient  has  pain — a  tender  spine  for  ex- 
"  ample ;  she  is  urged  to  give  it  rest.  She  cannot 
"  read ;  the  self-constituted  nurse  reads  to  her. 
"  At  last  light  hurts  her  eyes ;  the  mother  or  sister 
"  remains  shut  up  with  her  all  day  in  a  darkened 
"  room.  A  draught  of  air  is  supposed  to  do  her 


FORMS  OF  NEURASTHENIA.         97 

"  harm,  and  the  doors  and  windows  are  closed." 
And  Weir  Mitchell  rightly  adds :  "  To  cure  such 
"  a  case  you  must  morally  alter  as  well  as  physi- 
"  cally  amend,  and  nothing  less  will  answer.  The 
"  first  step  needful  is  to  break  up  the  companion- 
"  ship,  and  to  substitute  the  firm  kindness  of  a 
"  well-trained  hired  nurse."1 

3.  Genital  Neurasthenia. — This  is  an  essenti- 
ally male  form  of  neurasthenia.  Later  on,  in  con- 
nection with  the  theories  of  the  disease,  we  shall 
say  a  few  words  on  the  relation  that  some  have 
tried  to  establish  between  the  nervous  asthenia 
of  women  and  certain  lesions  of  the  uterus  or  its 
appendages.  The  genital  neurasthenia  that  we 
have  to  deal  with  here  has  nothing  to  do  with 
the  former  kind;  it  is  only  found  in  men,  and 
owes  to  the  circumstances  in  which  it  arises,  and 
the  symptoms  by  which  it  manifests  itself,  a 
sufficiently  special  physiognomy.  It  has  been  well 
described  by  Beard,  by  Ultzmann,  and  above  all 
by  Krafft-Ebing. 

If  we  are  to  believe  the  patients — and  authors 
have  echoed  too  complaisantly  their  way  of  look- 
ing at  the  matter — the  disorders  that  constitute  it 
are  usually  consecutive  to  sexual  excesses,  par- 
ticularly to  masturbation  during  adolescence, 
sometimes  also  to  excessive  coitus.  More  rarely 
they  follow  on  more  or  less  permanent  affections 
of  the  urethra,  notably  on  chronic  gonorrhoea. 

iWeir  Mitchell,  Fat  and  Blood,  7th  ed.,  pp.  40,  41. 
Neurasthenia.  7 


98  NEURASTHENIA. 

These  affections  or  excesses  bring  on  a  state  of 
erethism  of  the  centres  presiding  over  erection 
and  ejaculation,  and  later  a  state  of  atony  and 
inactivity  of  those  centres,  to  which  states  the 
various  symptoms  of  genital  neurasthenia  are  due. 

If  we  look  at  the  matter  closely,  the  exciting 
causes  invoked  by  the  patients  seem  to  us  to  have 
much  less  importance  than  is  attributed  to  them ; 
very  often  the  excesses  of  which  they  accuse 
themselves  do  not  go  beyond  the  customary  aver- 
age of  those  of  adolescents  and  adults.  It  is  else- 
where that  we  must  search  for  the  true  cause  of 
the  disorders  that  characterise  genital  neuras- 
thenia ;  the  young  people  who  are  affected  by  it 
generally  exhibit  undoubted  stigmata  of  degenera- 
tion. Hereditary  degenerates  or  not,  these  are 
people  in  whom  one  finds  signs  of  congenital  de- 
bility, transmitted  or  acquired,  of  the  nervous 
system :  infantile  convulsions,  nocturnal  inconti- 
nence of  urine  up  to  an  age  more  or  less  bordering 
on  adolescence,  malformation  of  the  ears,  in- 
sufficient or  exaggerated  development  of  the 
penis  or  testes,  morbid  timidity,  doubts,  scruples. 
In  fact,  these  patients  are  often  already  abnormal 
mentally  before  being  neurasthenic,  and  their 
neurasthenia  always  bears  the  stamp  of  fairly 
marked  cerebral  derangement ;  it  is  accompanied 
by  a  veritable  hypochondriacal  obsession. 

Among  the  symptoms  of  which  these  hypochon- 
driacs complain,  genital  symptoms  naturally  hold 


FORMS  OF  NEURASTHENIA.         99 

the  first  place :  these  are — frequent  and  exhaust- 
ing nocturnal  pollutions,  priapism,  and  speedy 
ejaculation  on  contact,  preventing  the  regular  and 
complete  accomplishment  of  sexual  connection. 
At  a  more  advanced  stage  there  is  real  impotence, 
which  however  is  more  psychical  than  spinal :  the 
patient  may  or  may  not  have  erections,  but  in  any 
case  the  erection  either  fails  altogether  to  occur, 
or  ceases  at  the  moment  of  the  physiological  act. 
If  the  disorder  is  still  more  marked,  emission  takes 
place  on  the  occasion  of  the  slightest  stimulus, 
such  as  an  erotic  thought,  the  sight  of  a  woman, 
or  even  light  friction  or  shaking  like  that  produced 
by  riding  or  by  the  jolting  of  a  carriage ;  these 
emissions,  moreover,  are  not  accompanied  by  any 
voluptuous  sensation.  It  may  even  happen  that 
spermatorrhoea  is  produced  without  the  least 
erection,  when  the  patient  makes  a  simple  effort 
of  micturition  or  defaecation.  In  this  last  case, 
indeed,  it  is  more  often  prostatorrhoea  than  true 
spermatorrhoea  that  is  present,  and  the  subjects 
frequently  mistake  for  spermatic  fluid  what  is 
simply  mucus  from  the  prostate  and  urethra. 

These  disorders  of  erection  and  ejaculation  are 
accompanied  by  distressing  sensations:  feelings 
of  burning  in  the  urethral  canal,  neuralgic  pains 
in  the  thighs  and  loins,  and  the  various  symptoms 
of  cerebro-spinal  neurasthenia,  viz.,  rachialgia, 
headache,  muscular  weakness,  dyspeptic  troubles, 
attacks  of  palpitation,  and  precordial  anxiety. 


100  NEURASTHENIA. 

But  what  gives  to  the  clinical  picture  a  fairly 
distinctive  physiognomy,  is  the  peculiar  psychical 
state  of  these  patients :  they  are  both  confused 
and  distressed  by  their  situation,  and  their  faces 
express  at  the  same  time  timidity,  shame,  and 
despondency.  They  usually  speak  little  and  in  a 
low  voice  ;  absorbed  by  their  morbid  preoccupa- 
tions, they  neglect  all  the  affairs  of  life  that  are 
unconnected  with  those  preoccupations.  It  is 
among  them  that  are  recruited  some  of  those  self- 
accusing  patients  with  delusions  of  persecution, 
to  whom  we  have  drawn  attention1;  despair  leads 
them  fairly  often  to  ideas  of  suicide,  and  some- 
times they  even  pass  from  the  idea  to  the  act. 

4.  Traumatic  Neurasthenia. — Traumatic  neur- 
asthenia comprises  a  form  whose  individuality  is 
not  less  marked  than  those  of  the  neurasthenia 
of  women  and  genital  neurasthenia.  Its  symptoms 
are  fairly  often  associated  with  those  of  hysteria, 
constituting  traumatic  hystero-neurasthenia.  To 

1G.  Ballet,  Lefons  de  clinique  medicals.  Paris,  1897.  Published  by 
O.  Doin. 

In  the  lecture  referred  to  Professor  Ballet  first  mentions  the  well- 
known  contrast  between  the  mental  attitude  of  melancholies  and 
that  of  most  patients  with  delusions  of  persecution  :  the  latter 
accuse  others  of  being  the  authors  of  their  misfortunes,  and  are 
aggressive  and  indignant,  whereas  the  former  blame  themselves  and 
are  humble  and  resigned.  He  then  points  out  that  there  is  a  class 
of  patients  with  delusions  of  persecution  whose  mental  attitude 
resembles  that  of  melancholies ;  these  patients  do  regard  them- 
selves as  persecuted  by  others,  but  they  consider  the  fault  as  lying 
in  the  first  instance  with  themselves ;  they  are  timid  and  self- 
depreciatory  because  they  believe  that  the  persecution  to  which 
they  imagine  themselves  subjected  is  due  to  some  lesion  or  defect 
or  bad  habit  of  their  own,  usually  or  always  connected  with  the 
genital  apparatus. — Trans. 


FORMS  OF  NEURASTHENIA.        101 

avoid  going  beyond  the  limits  of  this  book,  we 
shall  only  concern  ourselves  here  with  simple 
neurasthenia. 

Some  thirty  years  ago  the  medical  men  of  Eng- 
land and  America  (Liddell,  Syme,  Morris,  Savory) 
took  to  describing  under  the  name  of  Railway 
Spine  some  nervous  symptoms  of  diverse  nature 
that  they  had  observed  in  the  victims  of  railway 
accidents.  Erichsen  attributed  these  symptoms 
to  superficial  lesions  of  the  cord  and  brain  and 
their  envelopes  ;  Westphal  and  Leyden  associated 
themselves  with  this  point  of  view. 

Some  years  later,  in  1884  and  1885,  Oppenheim 
and  Thomsen  put  forward  a  different  opinion  as 
to  the  etiology  of  the  symptoms  in  question  :  they 
considered  them  as  simple  nervous  disorders,  but 
forming  by  their  physiognomy  a  special  clinical 
entity  different  from  the  neuroses  that  had  been 
described  up  till  then  ;  they  gave  to  this  entity 
the  name  of  traumatic  neurosis. 

However,  two  American  physicians,  Walton 
and  Putnam,  had  brought  out  clearly  the  analogy 
existing  between  some  of  the  symptoms  of  this 
neurosis  and  those  of  hysteria  as  it  was  then 
known.  Page  (1885)  had  made  similar  observa- 
tions. Charcot  about  this  period  applied  himself 
to  showing  that  the  different  disorders  described  as 
peculiar  manifestations  of  the  traumatic  neurosis 
were  after  all  only  those  of  hysteria  or  of  neuras- 
thenia, sometimes  isolated,  sometimes  associated. 


102  NEURASTHENIA. 

This  point  of  view  seems  to  us  indisputable. 
But  Charcot  went  rather  far  when,  after  rightly 
refusing  to  traumatic  neurasthenia  any  noso- 
logical  individuality,  he  also  refused  it  a  clinical 
individuality.  Now  it  is  not  correct  to  say  that 
traumatic  neurasthenia  cannot  be  differentiated 
from  neurasthenia  due  to  another  cause.  In  fact, 
in  the  majority  of  cases,  as  various  authors, 
notably  Mm.  Brouardel  and  Vibert,  have  asserted, 
it  has  a  fairly  distinct  physiognomy. 

Let  us  rapidly  review  its  causes  and  its  symp- 
toms. 

Traumatic  neurasthenia  may  be  the  consequence 
of  a  purely  personal  accident ;  it  may  declare 
itself  after  a  fall  from  a  horse  or  a  carriage,  after 
a  blow  on  the  head,  or  a  fall  from  scaffolding. 
More  frequently  it  is  due  to  catastrophes  in  which 
a  larger  or  smaller  number  of  individuals  is  im- 
plicated, as  earthquakes  or  railway  accidents.  It 
has  long  been  remarked  that  the  victims  who  are 
affected  by  the  malady  are  not  usually  those  who 
present  the  gravest  injuries  ;  this  is  because  trau- 
matic neurasthenia  is  due  much  less  to  the  physi- 
cal than  to  the  moral  shock,  that  is  to  say  the 
emotion  and  fright  occasioned  by  the  accident. 

Although  the  first  symptoms  may  show  them- 
selves fairly  promptly,  yet  in  general  they  do 
not  appear  till  some  days  and  occasionally  some 
weeks  after  the  event  that  has  provoked  them. 
Traumatic  neurasthenia  owes  its  characteristic 


FORMS  OF  NEURASTHENIA.        103 

physiognomy  chiefly  to  the  psychical  disorders, 
which  are,  at  least  in  typical  cases,  much  more 
marked  than  in  the  other  forms  of  neurasthenia. 

The  physiognomy  of  the  patients  expresses 
both  dejection  and  hebetude.  Their  walk  is  slow, 
embarrassed,  or  even  staggering;  they  advance 
with  short  steps  and  all  in  one  piece,  so  to  speak, 
as  if  the  joints  of  the  spinal  column  and  lower 
limbs  had  lost  their  flexibility.  Their  speech  is 
low,  hesitating,  sometimes  even  tremulous.  They 
have  great  difficulty  in  fixing  their  attention: 
thus  they  answer  questions  with  a  certain  diffi- 
culty, or  at  least  with  a  certain  slowness,  and 
they  complain  of  not  being  able  to  read  or  to 
work.  Their  memory  is  very  sluggish.  They  are 
excessively  emotional,  and  often  burst  into  tears 
as  soon  as  one  speaks  to  them  about  their  com- 
plaint and  the  causes  that  have  produced  it. 
They  suffer  from  violent  headache,  vertigo  and 
insomnia;  when  they  fall  asleep  they  are  tor- 
mented by  distressing  nightmares,  in  which  the 
mishaps  that  they  underwent  in  their  accident 
usually  fill  a  large  place. 

They  often  complain  of  sensory  troubles,  of  local 
pains,  numbness,  sensations  of  cold,  formication, 
burning  feelings  in  the  limbs;  of  asthenopia;  and 
of  humming  in  the  ears,  with  or  without  hyper- 
acousia. 

Muscular  asthenia  is  general  and  well-marked. 

As  with  most  neurasthenics,  there  are  disorders 


104  NEURASTHENIA. 

of  digestion,  but  here  the  gastro-intestinal  atony 
is  fairly  often  complicated  with  vomiting. 

The  pulse  in  many  cases  is  frequent,  and  at  the 
same  time  small,  and  sometimes  intermittent. 
Polyuria  and  glycosuria  may  be  observed.  Genital 
impotence  is  usual. 

To  sum  up,  one  finds  in  traumatic  neurasthenia, 
combined  or  not  with  hysteria,  the  various  symp- 
toms that  go  to  form  the  clinical  picture  of  ner- 
vous asthenia,  but  generally  in  a  much  more 
marked  degree. 

Finally,  the  incapacity  for  mental  effort,  the 
dejection,  the  aboulia,  and  the  special  facies 
caused  by  these  troubles,  give  the  patient  a 
physiognomy  sufficiently  distinctive  to  render 
traumatic  neurasthenia,  notwithstanding-  what 
may  have  been  said  to  the  contrary,  easy  to 
differentiate  in  most  cases  and  of  an  indisput- 
able clinical  individuality. 


THE    DISEASES    THAT    ARE    OFTEN    CON- 
FOUNDED   WITH    NEURASTHENIA. 
NEED   OF   A  PRECISE  DIAGNOSIS    BEFORE 
LAYING  DOWN  A  RATIONAL  COURSE 
OF   TREATMENT. 

The  fortunes  of  the  word  Neurasthenia  have 
been  remarkable ;  not  only  did  it  quickly  take  a 
place  in  the  medical  vocabulary,  but  it  soon 
became  popular.  Everybody  knows  it  and  makes 
use  of  it,  and,  as  in  the  case  of  all  technical  terms 
that  have  become  public  property,  it  has  been 
applied  at  random.  Just  as  there  is  hardly  an 
attack  of  fever,  cold  or  sore  throat  which  is  not 
ascribed  to  influenza,  so  there  is  no  nervous 
phenomenon  that  presents  itself,  which  is  not, 
provisionally  at  least,  termed  a  neurasthenic 
affection  by  the  patients,  their  friends,  and  some- 
times even  by  the  doctor. 

Thus  the  scope  of  neurasthenia  would  be  re- 
markably wide  and  varied  if  one  were  guided  by 
the  disorders  that  are  improperly  ascribed  to  it 
every  day. 


106  NEURASTHENIA. 

Now  the  confusion  of  a  nosological  species 
with  others  that  more  or  less  resemble  it,  has  the 
most  disastrous  consequences  in  practice.  It 
leads  not  only  to  mistakes  in  prognosis,  which 
alone  is  bad  enough,  but  also  to  errors  in  treat- 
ment, which  is  perhaps  more  serious. 

Hence  we  have  been  surprised  to  see  that  in  a 
recent  work,  which  in  other  respects  is  full  of 
correct  and  original  ideas,1  Dubois  (of  Berne), 
who  is  a  physician  of  great  judgment  and  experi- 
ence, reconciles  himself  to  this  confusion,  and 
dismisses  the  endeavour  to  arrive  at  a  precise 
diagnosis  as  a  vain,  useless  and  barren  labour. 
"  No  doubt,"  he  says,  "  scarlatina  and  measles 
"  are  as  much  morbid  entities  as  those  infective 
"  diseases  whose  micro-organisms  are  known  and 
"  cultivated.  And  the  same  is  the  case  with  the 
"  greater  number  of  organic  diseases,  even  when 
"  we  are  still  in  the  most  complete  ignorance  of 
"  their  etiology.  But  as  soon  as  we  enter  upon 
"  the  region  of  psychology,  this  respect  for  classi- 
"  fication  is  no  longer  possible.  Though  we  may 
"  continue  to  make  use  of  terms  that  are  conse- 
"  crated  by  usage,  to  employ  analysis,  and  even  to 
"  make  new  subdivisions  after  a  more  precise 
"  study  of  symptoms,  yet  we  are  also  compelled  to 
"  efface  distinctions  and  make  wider  generalisa- 
"  tions.  If  this  does  not  give  us  a  clear  view,  at 

iDubois,  Les  psychonevroses  et  leur  traitement  moral.   Paris:  Masson, 
1904. 


NEED  OF  AN  EXACT  DIAGNOSIS.    107 

"  any  rate   it  gives   us  a  bird's-eye  view   from 
"above." 

In  order  to  gain  a  clear  view  it  is  certainly  a 
good  thing  to  look  from  a  higher  elevation ;  one 
can  thus  appreciate  better  the  reciprocal  relations 
of  things ;  but  we  must  take  care  not  to  let  our 
balloon  mount  to  heights  from  which  details  can- 
not be  distinguished,  for  then  everything  becomes 
jumbled  and  confused ;  there  is  an  effacing  of 
fundamental  dissimilarities  between  diseases,  on 
which  dissimilarities  depend  differences  of  prog- 
nosis and  evolution  of  the  highest  importance. 
Thus  one  is  reduced  to  a  symptomatic  treatment 
which  is  hardly  better  than  quackery.  It  is  not 
for  the  simple  satisfaction  of  "  supplying  our 
patients  with  a  name  derived  from  Greek  "  or 
elsewhere,  that  the  need  has  been  felt  of  giving  a 
name  to  diseases,  after  having  separated  them 
from  one  another  by  a  long  and  laborious  work  of 
observation.  These  names  are  not  the  simple 
fantasies  of  philologists;  each  of  them,  on  con- 
dition that  they  are  applied  to  well  characterised 
entities,  implies  a  course,  an  evolution,  a  prognosis, 
and  a  treatment  which  differ  from  the  course, 
evolution,  prognosis,  and  treatment  of  neighbour- 
ing entities,  and  I  am  surprised  that  Dubois 
should  seem  to  suppose  the  contrary.  One  ex- 
ample will  enable  me  to  show  the  importance  of 
this  question  of  nomenclature.  In  1885  Lange 
(of  Copenhagen)  described  under  the  name  of 


108  NEURASTHENIA. 

"  periodic  depression  "  an  affection  characterised 
by  intermittent  and  recurrent  attacks  of  depres- 
sion. Lange  failed  to  observe  that  this  affection 
was  only  one  of  the  forms  of  the  disease  dis- 
covered more  than  fifty  years  ago  by  Falret  and 
Baillarger,  and  by  them  named  folie  circulaire  or 
folie  d  double  forme  (circular  insanity).  His  mis- 
take was  excusable  at  that  time  ;  to-day  it  would 
no  longer  be  so,  after  the  many  works  that  have 
been  written  on  the  periodical  psychoses,  both  in 
France  and  abroad,  especially  in  Germany.  Now 
the  term  invented  by  Lange  has  led  some  persons 
astray;  they  have  believed  in  the  existence  of 
a  special  disease,  though  the  name  referred 
only  to  a  special  form  of  a  known  disease. 
M.  Dubois  himself,  I  am  surprised  to  find, 
appears  to  be  one  of  these  persons  ;  and  though 
all  psychiatrists,  apart  from  the  question  of 
degree,  connect  the  various  forms  of  periodical 
psychoses  with  one  another,  and  recognise  the 
identity  of  their  essential  symptoms,  yet  he  fails 
to  recognise  this  identity,  and  considers  the  attacks 
of  intermittent  depression  to  be  acute  attacks  of 
neurasthenia.  This  is  all  the  more  astonishing 
because  the  resemblances  between  neurasthenia 
and  intermittent  melancholia  are  very  few  and 
very  superficial,  if  indeed  they  exist  at  all,  and 
on  the  other  hand  there  are  radical  differences 
between  them  in  their  clinical  appearance,  their 
etiology,  and  their  course. 


NEED  OF  AN  EXACT  DIAGNOSIS.    109 

M.  Dubois  may  ask  what  it  matters  from  the 
practical  point  of  view.  It  matters  much  :  the 
difference  in  the  course  of  the  two  complaints 
causes  the  prognosis  to  be  very  different,  and  the 
treatment  also.  So  far  as  I  know,  neither  psycho- 
therapy in  any  of  its  forms,  nor  any  other  mode  of 
treatment,  has  ever  shortened  by  one  hour  the 
duration  of  even  the  slightest  attack  of  "  periodic 
depression,"  any  more  than  that  of  the  most 
marked  attack  of  circular  insanity.  M.  Dubois 
seems  to  me  to  hold,  mistakenly,  the  contrary 
opinion.  I  am  sure  that  he  would  not  have  fallen 
into  this  error  if  he  had  had  less  disdain  for  the 
classification  of  diseases  and  the  nomenclature 
it  requires,  had  looked  from  a  less  elevated 
stand-point  at  the  malady  Lange  thought  he 
had  discovered,  and  had  seen  it  in  its  proper 
position. 

No,  distinctions  are  not  useless  and  vain,  and 
I  can  only  suppose  that  what  M.  Dubois  wrote 
went  further  than  what  he  really  thought.  Like 
all  neurologists,  among  whom  he  holds  a  very 
honourable  place,  he  must  have  seen  the  practical 
disadvantage  of  diagnoses  that  are  superficial, 
erroneous,  or  incomplete. 

In  dealing  with  neuroses  and  psychoses,  indeed, 
one  is  liable  to  make  the  most  incorrect  prog- 
nosis and  to  employ  the  most  deplorably  empiric 
and  barren  lines  of  treatment,  if  one  does  not 
make  an  exact  diagnosis  beforehand.  The  time 


110  NEURASTHENIA. 

has  passed  when  medical  men  contented  them- 
selves with  describing  all  patients  attacked  by 
nervous  disorders  as  neurotic,  and  the  progress 
which  clinical  observation  has  brought  about  in 
nosology  in  this  matter  cannot  be  ignored  or 
disdained  by  physicians  worthy  of  the  name, 
under  the  pretext — which  has  always  been  that  of 
the  ignorant — that  they  are  practical  in  their 
aim. 

Out  of  ten  patients  who  present  themselves  to 
a  neurologist  as  suffering  from  neurasthenia,  fully 
half  are  affected  by  some  quite  different  complaint; 
and  the  physician's  first  task  must  be  to  rectify 
the  erroneous  diagnosis  which  has  usually  been 
made  by  the  patient  himself  or  his  friends,  but 
sometimes  also  by  a  brother  medical  man  who 
takes  "  bird's-eye  views  "  and  disdains  nosological 
distinctions. 

If  we  were  to  draw  up  here  a  detailed  schedule 
of  all  the  maladies  that  are  improperly  described 
as  neurasthenia  at  one  stage  or  other  of  their 
course,  we  should  have  to  review  almost  the 
whole  field  of  nervous  diseases.  Moreover,  a 
chapter  on  differential  diagnosis  is  of  necessity 
always  summary,  insufficient,  and  in  some  respects 
artificial.  We  prefer  to  point  out  here  simply 
and  briefly  those  mistakes  that  are  commonest, 
and  therefore  principally  to  be  guarded  against. 

It  is  not  often  that  simple  neurasthenic  dis- 
orders are  taken  for  the  symptoms  of  a  lesion  of  the 


NEED  OF  AN  EXACT  DIAGNOSIS.    Ill 

nervous  system,  or  inversely.  Nevertheless  the 
error  is  possible  in  certain  cases,  and  sometimes 
even  excusable. 

We  will  mention  the  most  frequent. 

It  often  happens  that  a  patient  who  has  had 
syphilis  suffers  from  fatigue,  some  derangements 
of  digestion,  attacks  of  vertigo,  various  topoalgias, 
in  short  some  of  the  symptoms  of  nervous  asthenia, 
and  in  consequence  believes  himself  to  be  attacked 
by  locomotor  ataxy.  The  mistake,  or,  if  one  pre- 
fers the  expression,  the  fear,  is  particularly  com- 
mon among  medical  men  ;  the  phobia  of  ataxia  is 
especially  a  medical  phobia,  though  far  from  being 
exclusively  so.  In  such  a  case  it  must  be  re- 
membered that  tabes  is  characterised  not  only  by 
subjective  symptoms,  but  also  by  objective  signs 
of  the  greatest  importance :  Westphal's  sign 
(abolition  of  the  knee-jerks) ;  Argyll- Robert  son's 
sign  (absence  of  the  pupillary  reaction  to  light 
with  preservation  of  the  reaction  to  accommoda- 
tion) ;  Romberg's  sign  (oscillation  when  the  patient 
stands  up  and  shuts  his  eyes) ;  urinary  disorders 
(retention  or  incontinence)  ;  and  genital  disorders 
(impotence  and  frigidity). 

The  fear  of  general  paralysis  is  also  very  com- 
mon among  depressed  syphilitics,  who  are  ex- 
hausted by  worries,  and  whose  apprehensions  as 
to  the  possible  results  of  the  infection  are  not 
the  least  of  the  causes.  As  a  rule,  the  diagnosis 
in  these  cases  is  easy:  it  is  shown  by  absence 


112  NEURASTHENIA. 

of  spinal  symptoms  (lightning  pains,  exagger- 
ation or  absence  of  knee-jerks,  urinary  dis- 
orders, genital  disorders),  of  bulbar  symptoms 
(hesitating  speech,  trembling  of  the  tongue 
and  lips),  of  eye  symptoms  (inequality  of 
the  pupils,  Argyll- Robertson's  symptom,  motor 
pareses  of  the  eyes),  and  of  cortical  symptoms 
(distinct  failure  of  memory,  obvious  to  others, 
alterations  in  the  character,  irritability). 

It  must  not  be  forgotten,  however,  that  some 
cases  of  general  paralysis  begin  by  symptoms  re- 
calling those  of  neurasthenia,  that  in  these  cases 
the  symptoms  remain  subjective  for  a  long  time, 
even  for  several  years,  as  I  have  shown1,  and  that 
in  the  absence  of  objective  or  decisive  signs,  the 
diagnosis  remains  doubtful  and  uncertain.  I  have 
lately  insisted  on  certain  peculiarities  which  en- 
able these  false  preparalytic  neurasthenias  to  be 
distinguished  from  true  neurasthenia  (rapid  varia- 
tions in  the  symptoms  from  one  day  to  another, 
curious  nature  of  some  of  the  sensations  com- 
plained of  by  the  patients,  abnormal  intensity  of 
some  of  those  sensations,  etc.)  If  one  is  still  in 
doubt,  it  is  now  possible  to  clear  up  the  matter  by 
having  resource  to  lumbar  puncture,  as  it  has  been 
shown  that,  as  a  rule,  lymphocytosis  of  the  cere- 
bro-spinal  fluid,  which  is  absent  in  neurasthenics, 
is  present  more  or  less  abundantly  in  general 
paralysis  as  well  as  tabes. 

JG.  Ballet,  Laperiode  prodromique  d,  forme  neurasthinique  dans  la 
paralysis  generate,  in  Lemons  de  cliniques.     Paris  :  O.  Doin,  1897. 


NEED  OF  AN  EXACT  DIAGNOSIS.   113 

It  is  needless  to  draw  attention  to  the  possible 
confusion  between  neurasthenia  and  cerebral 
tumours.  This  confusion  never  lasts  long.  Even 
when  the  early  symptoms  are  such  as  to  excuse 
it,  it  is  promptly  cleared  up  as  a  rule  by  the  in- 
tensity of  the  headache,  the  vomitings,  and  the 
lesions  of  the  papilla  that  occur  in  the  case  of 
neoplasms. 

Neurastheniform  disorders,  such  as  persistent 
headache,  vertigo,  dyspepsia,  lassitude,  and  slight 
mental  depression,  are  sometimes  merely  a 
secondary  manifestation  of  an  underlying  organic 
condition — disease  of  the  kidneys,  liver  or  heart, 
increase  of  arterial  tension,  arthritic  auto-intoxi- 
cation, or  intoxication  of  external  origin.  One  has 
to  remember  them  to  understand  the  importance 
of  a  thorough  physical  examination  in  the  case  of 
every  patient  suspected  of  neurasthenia ;  without 
such  an  examination  one  would  be  liable  to  over- 
look the  various  disorders  with  which  the  nervous 
condition  is  closely  connected,  and  to  which,  in 
consequence,  the  treatment  must  be  subordinated. 

But  the  most  frequent  errors  of  diagnosis  are 
not  those  which  consist  in  mistaking  lesions  of 
the  brain  and  cord  or  of  the  viscera  for  simple 
nervous  disorders ;  the  most  common  are  the 
result  of  the  confusion  which  still  reigns  in  the 
minds  of  many  medical  men  on  the  subject  of  the 
various  neuroses  and  psychoses.  As  the  distinc- 
tive features  of  these  latter  are  still  insufficiently 

Neurasthenia  8 


114  NEURASTHENIA. 

known,  the  situation  is  simplified  by  jumbling  them 
all  together  under  the  same  caput  mortuum.  Now- 
adays one  hardly  dares  say  simply  "  nervous  dis- 
orders," as  formerly ;  one  says  "  neurasthenia  "  ; 
it  is  more  fashionable,  but  neither  more  precise 
nor  more  correct. 

It  is  not  possible,  in  a  book  like  this,  to  dwell 
upon  the  characters  and  the  clinical  features  of 
the  various  disorders  which  are  improperly  as- 
cribed to  neurasthenia  ;  we  should  have  to  go  over 
almost  the  whole  nosology  of  the  neuroses  and 
psychoses.  I  will  limit  myself  to  noticing  those 
classes  of  patients  who  appear  most  frequently 
before  the  neurologist,  and  whom  one  must  care- 
fully avoid  considering  as  suffering  simply  from 
nervous  asthenia. 

If  we  consider  them  merely  from  the  point  of 
view  of  the  symptoms  that  dominate  the  situation, 
we  may  class  the  patients  into  four  groups  : 

1.  The  asthenic. 

2.  Those  with  scruples,  doubts  and  phobias. 

3.  The  melancholic. 

4.  The  hypochondriacal. 

Each  of  these  groups  itself  includes  very 
different  diseases,  for  the  classification  we  have 
given  is  purely  symptomatic  and  not  nosological. 
Consequently  the  physician's  first  object  must  be 
to  recognise  to  which  of  these  four  groups  the 
patient  belongs,  and  then,  after  having  clearly 
determined  the  dominating  symptom,  to  connect 


NEED  OF  AN  EXACT  DIAGNOSIS.    115 

it  with  the   neurosis   or   psychosis  on   which  it 
depends. 

1.  The  asthenic  is  the  patient  who  is  the  sub- 
ject of  this  book.     In  his  case  the  characteristic 
phenomena  are  those  which  have  been  described 
above — persistent  headache,  rachialgia,  inaptitude 
for  work,  amyosthenia,  gastro-intestinal  atony — 
all  of  which  phenomena  are  expressive  of  nervous 
exhaustion.     On  this  basis  of  feebleness  are  often 
grafted  some  of  the  symptoms  of  the  other  groups 
—  scruples,     doubts,     phobias,    depression     re- 
sembling that  of   melancholies,  hypochondriacal 
obsessions  of  the  mind.  But  with  a  little  attention, 
and  a  little  of  the  habit  of  observation  in  nervous 
diseases,  one  can  soon  convince  oneself  that  these 
phenomena  are  accessory  and  secondary,  and  that 
their  prognosis  and  treatment  are  strictly  sub- 
ordinated to  the  prognosis  and  treatment  of  neur- 
asthenia itself. 

The  state  of  fatigue  and  cerebral  exhaustion 
that  is  more  or  less  marked  in  neurasthenics, 
predisposes  them  not  only  to  doubts,  phobias, 
melancholy,  and  hypochondriacal  obsessions,  but 
also  to  every  form  of  auto-suggestion.  That  is 
why  symptoms  of  hysteria  are  so  frequently  found 
associated  with  neurasthenic  phenomena  (hystero- 
neurasthenia).  This  association  is  the  rule  in  the 
traumatic  form  of  neurasthenia. 

2.  Those  with  scruples,    doubts   and  phobias 
differ  profoundly  from  the  neurasthenic.    In  them 


116  NEURASTHENIA. 

the  manifestations  are  no  longer  those  of  nervous 
exhaustion  ;  they  have  a  particular  form  of  loss  of 
brain  power — the  loss  of  power  to  attain  a  feeling 
of  certainty.  For  at  bottom,  below  the  various 
symptoms  that  we  are  considering,  there  is  always 
a  doubt :  a  doubt  of  any  form,  constituting  the 
maladie  du  doute  properly  so  called ;  a  doubt  in 
the  domain  of  morals,  constituting  a  scruple ;  a 
doubt  as  to  the  possible  harmfulness  of  an  object 
or  an  act,  constituting  a  phobia.1 

We  have  stated  above  that  doubt  may  be  an 
accidental  concomitant  of  neurasthenia.  But 
when  it  depends  on  the  latter,  and  forms  a 
secondary  symptom  of  it,  it  is  as  a  rule  slightly 
marked,  transient,  and  easily  curable.  On 
other  occasions,  however,  it  is  doubt  that 
occupies  the  foremost  place  in  the  clinical 

iThere  seems  to  be  some  confusion  due  to  the  double  meaning  of 
the  word  doubt.  Sometimes  it  refers  to  a  condition  of  the  will,  and 
is  opposed  to  confidence  or  decision  ;  at  other  times  it  is  opposed 
to  certainty,  and  refers  to  a  condition  of  the  intellect.  In  the  ex- 
pression maladie  du  doute  it  is  evidently  used  in  the  former  sense, 
for  there  is  not  necessarily  any  intellectual  derangement ;  even 
when  the  difficulty  consists  in  coming  to  a  definite  conclusion  on  a 
purely  intellectual  question,  the  fault  lies  with  a  disordered  will, 
which  hinders  the  two  sides  of  the  question  from  being  presented 
together  and  weighed  against  each  other  (see  p.  122,  lines  3  and  2 
from  bottom).  In  the  text  here,  however,  the  author  appears  to  use 
the  word  doubt  in  its  intellectual  connotation. 

The  word  phobia  also  seems  to  be  used  in  two  senses.  No  doubt 
certain  sufferers  from  the  maladie  du  doute  show  a  degree  of  timidity 
to  which  the  term  phobia  may  be  applied ;  Prof.  Ballet's  hypo- 
chondriacal  phobias  (p.  121)  seem  to  be  phobias  of  such  a  nature, 
associated  with  hypochondriasis  minor.  But  this  timidity  is  very 
different  from  the  phobias  in  which,  when  the  suitable  conditions 
arise,  the  patient  is  seized  with  sudden  terror  and  precordial 
anxiety,  a  state  in  which  doubt  finds  no  place  whatever.  Of  course 
there  may  be  cases  in  which  the  maladie  du  doute  is  associated  with 
true  phobias. — Trans. 


NEED  OF  AN   EXACT  DIAGNOSIS.    117 

picture,  and  is  complicated  by  secondary  pheno- 
mena of  loss  of  brain-power.  These  pheno- 
mena (moral  incompleteness,  loss  of  the  sense 
of  reality,  etc.),  which  have  been  well  studied 
by  P.  Janet,1  are  complications  of  the  grave 
and  inveterate  form  of  the  maladie  du  doute. 
Janet  has  proposed  to  employ  the  term  Psychas- 
thenia  to  denote  the  sum-total  of  the  symptoms 
from  which  these  patients  suffer.  In  our  opinion 
it  is  a  pity  to  change  the  meaning  of  the  word  in 
this  way  ;  as  used  at  present,  it  serves  to  denote 
the  mental  fatigue  and  the  inability  for  brain  work 
of  simple  neurasthenics.  It  is  not  a  wide  enough 
term  for  the  strongly  marked  border-land  cases 
that  Janet  had  in  view. 

However  this  be,  the  doubter,  such  as  the  neu- 
rologist sees  him  every  day,  differs  greatly  from 
the  neurasthenic,  both  in  the  symptoms  he  com- 
plains of,  and  in  the  course  and  the  usual  evolution 
of  those  symptoms.  He  is  above  all  a  psycho- 
path, such  as  were  lately  classed,  rightly  or 
wrongly,  in  the  somewhat  confused  group  of  de- 
generates ;  in  his  case,  apart  from  exceptions, 
one  does  not  observe  any  of  the  characteristic 
symptoms  of  nervous  asthenia — persistent  head- 
ache, rachialgia,  gastro-intestinal  atony,  or  amyos- 
thenia.  If  these  disorders  do  happen  to  be  present, 
they  constitute  associated  phenomena  which  have 
nothing  to  do  with  the  essential  mental  state  of 

1P.  Janet,  Les  obsessions  et  la  psychasthenie.     Paris  :  Alcan,  1903. 


118  NEURASTHENIA. 

the  patient ;  unless  the  doubts  themselves  are 
those  secondary  doubts  that  sometimes  compli- 
cate neurasthenia,  in  which  case  they  are  slightly 
marked  and  fairly  easily  curable.  Moreover,  the 
evolution  of  the  symptoms  shown  by  the  doubter 
is  different  from  that  of  neurasthenic  disorders. 
The  latter  have  a  certain  continuity,  and,  if  once 
cured,  they  may  not  reappear  if  the  causes  to  which 
they  were  originally  due  are  not  reproduced.  On 
the  other  hand  scruples,  doubts,  and  phobias,  ex- 
cept when  they  have  the  continuity  and  persistence 
that  is  only  seen  in  the  severest  forms,  occur  in- 
termittently, in  attacks  that  last  a  longer  or  a 
shorter  time;  in  the  intervals  of  these  attacks 
the  patients,  though  no  doubt  they  continue  to  be 
hesitating,  do  not  suffer  from  the  throes  of  dis- 
tress that  are  present  during  the  paroxysms.  Psy- 
chotherapy by  persuasion,  which  renders  such 
services  in  neurasthenia,  and  suggestion,  which  is 
so  useful  in  hysteria,  have  very  little  scope  here. 
This  is  natural,  as  neither  are  the  troubles  due  to 
auto-suggestion,  nor  are  they  simply  morbid 
habits,  but  they  consist  of  a  constitutional  state  of 
cerebral  imperfection. 

3.  The  melancholic  is  daily  taken  for  a  neuras- 
thenic. The  error  is  all  the  more  surprising,  as  it  is 
easy  to  see  the  features  in  which  the  two  differ, 
whereas  one  would  search  in  vain  for  a  point  of 
resemblance.  The  melancholic  condition,  what- 
ever be  its  nature,  is  made  up  of  disorders  of 


NEED  OF  AN  EXACT  DIAGNOSIS.    119 

which  some  are  constant  and  fundamental,  the 
others  secondary  and  inconstant,  though  usual. 
The  primitive  and  constant  phenomenon  is  an 
emotional  disorder ;  it  is  a  more  or  less  clearly 
conscious  state  of  prostration  and  powerlessness, 
and  consequently  of  despondency  and  distress. 
This  affection  of  the  emotional  side  of  the  mind 
results  in  sluggishness  of  the  intellect,  partial  or 
complete  inertia  of  the  will,  slowness  in  the 
movements,  and  aboulia.  The  accessory  disorders 
are  the  consequence  of  the  subconscious  operations 
of  the  patient's  mind  in  its  endeavour  to  interpret 
the  modifications  in  its  emotions  ;  they  consist  of 
false  ideas  of  unworthiness,  guilt  or  ruin,  or,  more 
rarely,  of  hypochondriacal  notions.  There  is  a 
complete  contrast  with  neurasthenia.  And  this 
contrast  is  still  more  marked  if  one  looks  at  the 
course  of  the  disease.  Melancholia  proceeds  by 
attacks,  short  or  long,  which  may  begin  suddenly 
and  end  in  the  same  way,  and  with  inevitable  re- 
currences at  longer  or  shorter  intervals,  at  least 
in  what  is  much  the  commonest  form,  intermittent 
melancholia. 

The  diagnosis  is  all  the  more  indispensable,  as 
the  treatment  of  melancholia  differs  altogether 
from  that  of  neurasthenia. 

4.  Hypochondria  is  often  spoken  of  ;  the  word 
is  sometimes  used  wrongly,  and  almost  always 
without  a  clear  conception  of  the  nature  of  the 
condition  it  denotes. 


120  NEURASTHENIA. 

Hypochondria  is  not  a  disease ;  it  is  a  symptom, 
and  its  clinical  and  nosological  significance  vary 
according  to  the  form  it  assumes.  It  consists  in 
"  a  state  of  worry,  clearly  exaggerated  or  even 
unfounded,  about  the  bodily  health."1  There  was 
a  time  when  neurasthenics  were  mistaken  for 
hypochondriacs  ;  they  were  too  readily  taken  to 
be  malades  imaginaires.  The  descriptions  of  the 
complaint  given  by  Beard  and  those  who  followed 
him,  showed  how  erroneous  this  conception  was. 
Nowadays  we  find  that,  by  the  usual  swing  of  the 
pendulum,  some  authors  seem  to  have  a  tendency 
to  return  to  the  former  point  of  view  :  for  them 
neurasthenia  has  again  become  a  disease  of  the 
imagination,  since,  in  accordance  with  the  tend- 
ency to  which  I  have  alluded,  its  symptoms  are 
supposed  to  be  images  of  suffering  or  discomfort 
fixed  in  the  mind  by  habit,  and  devoid  of  any  real 
physical  cause.  We  have  elsewhere  given  our 
opinion  on  this  point.  Neurasthenia,  whatever  be 
its  etiology,  consists  in  a  state  of  nervous  exhaus- 
tion ;  now  nervous  exhaustion  is  something  real, 
which  can  be  appreciated  and  even  measured.  It 
is  this  exhaustion,  the  essential  constituent  ele- 
ment of  the  affection,  to  which  treatment  must 
primarily  and  principally  be  directed.  On  this 
stock,  however,  defective  ways  of  feeling  and  re- 
acting readily  come  to  be  grafted,  and  also  fixed 

i  Pierre  Roy.  De  I'hypochondrie.  Etude  pathogenique  et  nosologique. 
(Report  presented  to  the  Congress  of  Alienists  and  Neurologists  of 
France,  Rennes,  1906). 


NEED  OF  AN  EXACT  DIAGNOSIS.    121 

ideas  that  are  erroneous  and  false  ;  and  it  is  thus 
that  hypochondriacal  notions  may  be  associated 
with  neurasthenia  as  a  complication.  But,  just 
as  in  the  case  of  scruples  and  doubts,  they 
are  only  a  complication  or  a  consequence  when 
they  do  appear.  Moreover  they  are  closely 
akin  to  scruples  and  doubts  in  nature  if  not 
in  form. 

The  hypochondria  of  the  neurasthenic,  which 
I  have  proposed  to  call  hypochondriasis  minor  in 
opposition  to  fixed  hypochondriacal  phobias  and  to 
hypochondriasis  major,  consists  not  so  much  of  a 
genuine  false  conviction  as  of  an  apprehension  or 
fear ;  the  mind  does  not  affirm,  but,  in  a  certain 
measure,  it  doubts.  It  is  a  sort  of  phobia,  but  one 
analogous  to  the  other  neurasthenic  phobias,  less 
persistently  harassing,  less  distressing  at  least, 
than  those  that  are  observed  in  true  doubters. 
The  neurasthenic  hypochondriac  is  amenable  to 
reason ;  he  readily  lets  himself  be  convinced  by 
arguments,  when  they  are  well  put  before  him, 
and  if  it  is  sometimes  difficult  to  cure  his  painful 
and  unpleasant  sensations  by  moral  suasion,  it  is 
usually  easy  to  dissipate,  for  a  time  at  least,  the 
erroneous  and  harassing  ideas  to  which  those 
sensations  have  given  rise. 

Near  the  patient  suffering  from  neurasthenic 
hypochondria  (hypochondriasis  minor)  must  be 
classed  the  man  whose  morbid  apprehension  is  a 
simple  form  of  the  maladie  du  doute.  These 


122  NEURASTHENIA, 

hypochondriacs,  whose  fear  assumes  proportions 
equal  to  those  of  the  most  distressing  of 
obsessions,  are  legion.  They  are  usually  re- 
garded as  neurasthenics,  as  malades  imaginaires, 
or  even  as  persons  wandering  in  their  minds. 
It  is  not  observed  that  these  are  sufferers 
from  simple  phobia,  whose  phobia  is  connected 
with  anxieties  about  their  health,  just  as  it 
might  have  been  connected  with  any  other 
subject,  with  contact  for  example.  The  funda- 
mental symptomatology  here  is  the  same  as 
in  all  other  kinds  of  phobias  :  doubt- fear 
(relating  to  health  in  this  particular  case), 
obsession  by  this  doubt,  and  consecutive  distress  ; 
and  the  progress  of  the  affection,  by  paroxysms, 
is  identical  with  that  of  the  other  forms  of  the 
maladie  du  doute.  Reasoning  and  suasion  have 
little  effect  on  hypochondriacs  of  this  class.  The 
fact  is  that  there  is  no  need  to  convince  them 
that  they  are  deceiving  themselves ;  they  know 
it  as  well  as  their  doctors  do.  It  is  rarely  that 
they  are  under  any  delusion  as  to  the  ground- 
lessness of  their  apprehensions ;  they  suffer  from 
their  besetting  fear  though  they  are  quite  aware 
that  it  is  unfounded  ;  they  are  disturbed  by  it  just 
as  we  sometimes  are  in  ordinary  life  at  the 
thought  of  a  danger  that  we  know  to  be  chimeri- 
cal. It  is  not  that  their  knowledge  is  affected, 
but  that  their  minds  are  undecided  ;  they  suffer 
from  hypochondriasis,  just  as  others,  who  are 


NEED  OF  AN  EXACT  DIAGNOSIS.    123 

fundamentally  identical  with  them,  suffer  from 
scruples. 

Quite  different  is  the  hypochondriac  of  the 
third  group,  with  whom  I  have  still  to  deal.  This 
one  has  true  delusions,  whether  his  morbid  idea 
is  free  from  absurdity  in  itself  (e.g.  the  conviction 
that  he  has  cancer  of  the  stomach),  or  on  the 
other  hand  is  obviously  absurd  at  first  sight  (e.g. 
the  conviction  of  having  a  serpent  in  the  intes- 
tines). He  is  not  simply  apprehensive,  like  the 
first  kind  of  hypochondriac,  nor  a  doubter  beset 
by  a  phobia,  like  the  second  ;  he  is  convinced  ;  fear 
has  given  place  to  a  decided  belief,  a  fixed  idea. 
There  is  a  true  partial  disorder  of  the  intellect, 
and  the  features  that  determine  its  symptomato- 
logical  importance,  its  significance  as  regards 
diagnosis  and  prognosis,  and  finally  the  thera- 
peutic indications  depending  on  these,  are  the 
same  as  in  other  partial  disorders  of  the 
intellect. 

5.  In  these  last  years  there  has  been  des- 
cribed1, as  an  independent  neurosis,  an  affection 
whose  place  in  nosology  is  still  under  dispute,  but 
whose  clinical  features  are  sufficiently  special  to 
necessitate  a  few  words  on  the  subject.  As  a 
matter  of  fact  it  is  often  called  simply  neuras- 
thenia, like  so  many  other  nervous  disorders  that 
have  nothing  to  do  with  neurasthenia.  We  refer 

1  Freud,    Neurol.    Centralblatt,    1895 ;     Hartenberg,    La    nevrose 
d'angoisse  (Paris :  Alcan,  1901),  and  Presse  Medicate,  Nov.  1906. 


124  NEURASTHENIA. 

to  the  neurosis  of  anxiety1.  Whatever  be  the 
points  of  relationship  that  connect  the  neurosis  of 
anxiety  with  neurasthenia,  with  obsessions,  or 
even  with  melancholia2,  its  clinical  appearance  is 
typical  enough.  The  patients  show,  whether  in 
a  marked  degree  or  not,  a  basis  of  neurasthenia 
resulting  from  disappointment  (love  troubles  most 
often  if  not  always),  with  a  diffuse  and  vague  state 
of  disquiet,  continuous  apprehensiveness,  and 
paroxysms  of  anxiety  that  occur  chiefly  in  the 
morning.  This  state  of  continuous  insecurity,  as 
Brissaud  says,  together  with  intermittent  attacks 
of  anxiety,  gives  the  complaint  an  altogether 
special  physiognomy,  which  distinguishes  it  clearly 
from  common  neurasthenia,  in  symptoms  at  least, 
if  not  in  nosology.  It  is  all  the  more  important 
not  to  confuse  the  two,  as  the  neurosis  of  anxiety 
requires  a  special  line  of  treatment,  that  of  all  the 
great  states  of  anxiety. 

This  rapid  review  of  the  conditions  that  are 
daily  and  very  improperly  taken  for  simple  neuras- 
thenia will  have  been  insufficient  to  give  a  com- 
plete notion  of  their  characters,  their  varied 

l « Nevrose  d'angoisse."  In  the  original  this  is  followed  by  a 
sentence  distinguishing  between  the  French  words  angoisse  and 
anxiete,  and  suggesting  that  nevrose  d'anxiete  would  be  a  better  name 
for  the  affection  than  nevrose  d' angoisse.  The  sentence  is  as 
follows :  "  It  would  be  better  to  call  this  nevrose  d'anxiete,  if  it 
were  agreed,  as  Brissaud  justly  proposes,  to  distinguish  angoisse, 
a  physical  disorder  characterized  by  a  sense  of  constriction  and 
suffocation,  from  anxiete,  which  is  a  psychical  disorder  that 
manifests  itself  by  an  indefinable  feeling  of  insecurity." — Trans. 

2  On  this  subject  see  the  report  of  the  Congress  of  Alienists  and 
Neurologists,  held  at  Grenoble,  1902.  (Published  by  Masson.) 


NEED  OF  AN  EXACT  DIAGNOSIS.    125 

forms,  and  their  nature.  Perhaps,  however,  it  has 
indicated  the  characteristic  features  of  each  of 
them  enough,  at  least,  to  bring  out  clearly  the  im- 
portance of  an  exact  diagnosis,  when  one  has  to 
deal  with  what  seems  to  be  simple  neurasthenia. 
Good  hygiene  and  therapeutics  cannot  be  had 
without  such  diagnosis. 


PART  IV. 
ETIOLOGY. 

We  propose  to  examine  in  this  chapter  the 
theories  that  have  been  put  forward  with  a  view 
to  throwing  light  on  the  etiology  of  neurasthenia. 
None  of  these  theories  seems  to  us  applicable 
to  the  sum-total  of  the  facts;  but  each  of  them 
contains  a  part  of  the  truth  and,  consequently,  a 
valuable  indication  for  the  prophylactic  or 
therapeutic  treatment  of  the  affection. 

a.  Gastric  Theories. — Physicians  have  at  all 
times  striven  to  subordinate  neuroses  in  general, 
and  consequently  the  different  symptoms  of 
neurasthenia,  to  some  lesion  or  functional  dis- 
order of  the  stomach  or  of  the  other  abdominal 
viscera.  In  these  pathogenic  conceptions  it  is 
sometimes  a  peccant  humour  engendered  by  the 
unhealthy  stomach,  spleen,  or  liver,  sometimes  a 
vague  nervous  influence,  a  reflex  action,  that 
serves  as  intermediary  between  the  organ  prim- 
arily attacked  and  the  nervous  system  secondarily 
affected.  Thus  Galen  with  his  atrabilis,  and  van 
Helmont  with  his  archcetts,  were  only  the  remote 
forerunners  of  Broussais  and  Beau,  in  sustaining 


ETIOLOGY.  127 

that  neuropathic  states  had  either  gastritis  or 
dyspepsia  for  their  origin.  Our  epoch  has  seen  the 
reappearance  of  analogous  pathogenic  systems, 
founded  this  time,  however,  on  more  precise 
observations,  resulting  from  a  relatively  perfected 
technique.  The  most  important  of  these  modern 
theories,  which  ascribe  the  origin  of  neurasthenic 
conditions  to  disorders  of  the  gastric  functions,  is 
that  which  has  been  upheld  by  Professor 
Bouchard. 

1.  Theory  of  Auto-intoxication. — The  doctrine 
of  M.  Bouchard  is  as  follows :  under  the  influ- 
ence of  various  causes,  and  in  virtue  of  heredit- 
ary or  congenital  weakness  of  the  muscular  walls 
of  the  stomach,  this  organ  contracts  insufficiently 
in  the  intervals  between  different  periods  of 
digestion.  The  digestive  fluids  (saliva,  mucus,  and 
gastric  juice),  mingled  with  remnants  of  food, 
tend  to  remain  in  it,  to  ferment,  and  to  putrefy, 
all  the  more  so  that  the  gastric  juice  no  longer 
contains  hydrochloric  acid  in  sufficient  proportion 
to  resist  the  action  of  the  ferments. 

These  abnormal  fermentations  continually  pro- 
duce soluble  toxins  which,  when  re-absorbed,  go 
to  impair  in  varying  degrees  the  anatomical 
elements  of  the  different  organs,  and  notably  the 
nervous  centres.  Among  the  morbid  phenomena 
that,  according  to  M.  Bouchard,  depend  on  the 
condition  of  the  stomach,  figure  indeed  all  the 
major  symptoms  of  neurasthenia  :  fatigue,  a 


128  NEURASTHENIA. 

feeling  of  exhaustion  as  soon  as  the  patient  wakes, 
headache,  inaptitude  for  work,  vertigo,  laborious 
digestion,  accompanied  by  general  and  local 
malaise,  etc. 

Criticisms  of  this  theory  have  not  been  want- 
ing. First  of  all,  it  has  been  remarked  that  dila- 
tation and  gastric  stasis  are  absent  in  a  great 
many  cases ;  in  the  second  place,  it  is  certain  that 
there  are  neurasthenics  who  have  never  exhibited 
any  disorder  of  the  digestive  functions.  It  has 
certainly  been  said  that  dilatation  of  the  stomach 
may  show  no  symptoms,  and  may  subsist  in  a 
latent  state  without  concomitant  manifestation  of 
dyspepsia;  but  exploration  by  means  of  the 
stomach-tube  has  enabled  the  absence  of  any 
gastric  stasis  to  be  directly  verified  in  a  crowd  of 
cases.  On  the  other  hand,  the  absence  or  de- 
ficiency of  hydrochloric  acid,  which  constitutes 
one  of  the  essential  elements  of  this  pathogenic 
doctrine,  is  frequently  wanting  in  dyspeptic  con- 
ditions, and  we  have  seen  that  it  is  not  rare  to 
encounter  excessive  secretion  of  hydrochloric  acid. 
Finally,  it  has  been  said,  if  the  nervous  dis- 
orders of  neurasthenia  are  the  effect  of  auto- 
intoxication from  the  stomach,  how  comes  it  that 
subjects  affected  by  great  gastric  dilatation,  due, 
for  example,  to  stenosis  of  the  pylorus,  and  accom- 
panied by  permanent  stasis,  never  present  the 
series  of  nervous  symptoms  attributed  to  gastric 
dilatation  ?  These  objections  are  evidently 


ETIOLOGY.  129 

sufficient  to  prove  that  the  theory  of  gastric 
dilatation  and  auto-intoxication,  though  applicable 
perhaps  to  some  cases  of  nervous  exhaustion,  is 
not  so  to  all. 

2.  Theory  of  the  Vitiation  of  Nutrition  by 
Dyspeptic  States. — Mm.  Hayem  and  Winter 
have  lately  taken  up  again  the  theory  formerly 
defended  by  Beau :  they  suppose  that  dyspepsia, 
whatever  may  have  been  its  exciting  cause,  and 
whether  it  be  accompanied  by  gastric  dilatation 
or  not,  brings  on  in  the  long  run  anaemia  of  the 
patients,  with  a  general  disturbance  of  the  nu- 
trition of  their  tissues  and  of  their  nerve  elements 
in  particular.  In  their  studies  on  the  pathological 
chemistry  of  the  stomach,  these  authors  attribute 
the  general  disorders  that  follow  on  dyspeptic 
conditions  to  albuminoid  products  derived  from 
qualitative  modifications  undergone  by  the  gastric 
digestion,  much  more  than  to  toxins  engendered  by 
fermentation.  Gastropathies,  whose  origin  often 
goes  back  as  far  as  infancy  or  adolescence,  supply 
the  tissues  with  nutritive  products  of  vicious 
composition,  and  thus  lead  to  various  disorders  of 
nutrition,  and  doubtless  also,  in  a  certain  number 
of  cases,  to  minute  alterations  of  the  nerve 
centres  which  give  rise  to  the  symptoms  of 
nervous  exhaustion.  This  conception  being 
admitted,  can  it  serve  as  basis  for  a  pathogenic 
interpretation  of  neurasthenic  states  in  general  ? 
We  do  not  think  so,  for  the  following  reasons : 

Neurasthenia  9 


130  NEURASTHENIA. 

there  are  undoubtedly  neurasthenics  who,  what- 
ever be  the  frequency  of  dyspeptic  troubles  in 
other  patients  of  this  class,  do  not  exhibit  any 
abnormality  or  disorder  of  their  digestive  func- 
tions. We  might  easily  bring  forward  examples 
of  hereditary  neurasthenia,  or  of  pure  cere- 
brasthenia,  in  which  the  general  nutrition  and  the 
gastric  functions  have  not  undergone  any  per- 
ceptible damage.  And  then  cases  are  frequent  in 
which  a  violent  and  sudden  emotion,  a  traumatic 
shock,  or  some  other  cause,  has  provoked  the  rapid 
and  simultaneous  appearance  of  the  digestive  dis- 
orders and  the  other  neurasthenic  symptoms.  In 
cases  like  this,  where  the  development  of  the 
dyspeptic  condition  and  the  appearance  of  the 
various  manifestations  of  the  neurosis  have  been 
contemporary,  the  genesis  of  the  whole  neur- 
asthenic group  of  symptoms  cannot  be  due  to  the 
disorder  of  the  digestive  functions  only.  Having 
made  these  reservations,  we  must  recognise  that 
dyspepsia  sometimes  precedes  the  neurasthenic 
state ;  in  such  cases  the  gastro-intestinal  origin  of 
the  nervous  exhaustion  is  at  least  probable.  In 
fact,  one  meets  with  patients  who,  before  they  be- 
came neurasthenic,  had  suffered  from  their 
stomachs  for  months  or  even  years.  Whether  they 
were  primarily  attacked  by  atonic  dyspepsia  with 
diminished  secretion  of  hydrochloric  acid,  or  by 
dyspepsia  with  hyperacidity,  accompanied  or  not 
by  hypersecretion  of  the  gastric  juice,  they 


ETIOLOGY.  131 

grew  thin  and  lost  their  strength ;  their  general 
nutrition  was  seriously  impaired.  When,  after  a 
longer  or  shorter  period,  during  which  the  diges- 
tive disorders  alone  filled  the  scene,  one  sees  the 
customary  train  of  neurasthenic  symptoms  appear 
in  these  patients,  nothing  is  more  legitimate  than 
to  impute  the  development  of  the  neurosis  to  the 
disorder  of  the  digestive  functions.  But  here 
again  we  may  ask  if  it  is  really  by  vitiating  the 
nutrition  of  the  elements  of  the  nerve-centres 
that  the  dyspepsia  has  engendered  the  neuro- 
pathic state.  Must  we  not  also  take  into  con- 
sideration, in  cases  of  this  class,  the  depressing 
influence  always  exerted  on  the  moral  state  of  the 
patients  by  a  gastric  affection  rebellious  to  the 
most  diverse  modes  of  treatment,  a  distressing 
and  irritating  source  of  incessant  discomforts  and 
disquietude  ?  In  whatever  manner  the  reaction 
of  the  gastro-intestinal  disorder  on  the  nervous 
centres  be  interpreted,  it  is  none  the  less  true 
that  the  dyspeptic  state  must  here  be  considered 
as  the  principal  factor  in  the  production  of  the 
disease. 

In  short,  the  relations  between  dyspeptic  states 
and  neurasthenia  may,  we  think,  be  summed  up 
as  follows :  in  the  majority  of  patients  suffering 
from  nervous  exhaustion  the  dyspepsia  has  merely 
the  value  of  a  symptom,  but  of  an  important 
symptom,  since  it  may  contribute  largely  to  keep- 
ing up  the  neuropathic  state.  In  certain  cases, 


132  NEURASTHENIA. 

however,  the  disorder  of  the  digestive  functions 
has  been  the  primary  cause  of  the  development 
of  the  neurasthenia;  and  it  is  against  it  that  the 
treatment  must  principally  be  directed. 

3.  Ptosis  of  the  Abdominal  Viscera. — M. 
Glenard  has  tried  to  explain  both  dyspepsia  and 
the  neurotic  state,  which  comprises  the  greater 
number  of  the  neurasthenic  symptoms,  by  a  sink- 
ing of  the  viscera  in  the  abdominal  cavity.  But 
later  researches  have  led  this  author  to  attribute 
to  an  ill-determined  derangement  of  the  hepatic 
functions  the  group  of  dyspeptic  and  neuropathic 
phenomena  that  he  observed  in  his  patients 
(hepatic  neurasthenia  of  Glenard  and  F.  Lagrange). 

It  is  certain  that  enteroptosis  exists  in  some 
neurasthenics,  but  it  is  also  incontestable  that 
this  symptom  is  absent  in  the  majority  of 
them.  Moreover,  M.  Glenard  recognises  that  the 
neuropathic  group  of  symptoms  that  he  has  in 
view  is  not  neurasthenia  as  defined  by  Beard  and 
the  authors  who  have  described  it  since.  It  is 
true  that  ptosis  of  the  abdominal  viscera  may  be 
accompanied  by  nervous  troubles ;  but  it  is  evi- 
dent that  it  cannot  serve  as  the  basis  of  a  patho- 
genic theory  of  neurasthenia. 

b.  Genital  Theory.  —  When  describing  the 
genital  form  of  neurasthenia,  we  saw  that  utero- 
ovarian  affections  in  women,  and  in  men  onanism, 
excessive  sexual  connection,  and  venereal  dis- 
eases, might  be  the  starting  point  or  exciting 


ETIOLOGY.  133 

cause  of  a  well-marked  neurasthenic  state.  But 
it  is  clear  that  organic  lesions  and  functional  dis- 
orders of  the  genital  system  do  not  exert  any 
specific  action  on  the  nervous  centres.  Their 
value  is  only  that  of  one  powerful  factor  of  ner- 
vous exhaustion  among  so  many  other  factors, 
and  nothing  more.  If  they  are  frequently  found  at 
the  origin  of  neurasthenic  states,  it  is  because 
they  act  with  peculiar  intensity  on  the  moral  con- 
dition of  the  patients  by  the  gloomy  ideas,  the 
disquietude,  and  the  fears  that  they  keep  up. 

c.  Yaso-motor  Theory. — Anjel  was  struck  by 
the  frequent  occurrence  of  vaso-motor  disorders 
in  neurasthenics,  and  made  an  attentive  study  of 
them.1  By  means  of  the  plethysmograph  he 
showed  that  in  these  patients  the  vaso-motor 
system  is  more  excitable  and  more  readily  ex- 
hausted than  in  normal  subjects.  If  Mosso's 
apparatus  be  applied  to  the  arm  of  a  normal  in- 
dividual, and  the  patient  be  then  asked  to  perform 
some  intellectual  work  (reading  or  calculation), 
it  is  observed  that  the  volume  of  the  arm 
immediately  lessens;  this  is  due  to  contraction  of 
the  arteries.  This  state  of  spasm  continues  as 
long  as  the  cerebral  activity  lasts,  and  comes 
rapidly  to  an  end  as  soon  as  the  brain  ceases 
work.  If  the  experiment  be  again  tried,  this  time 
on  a  neurasthenic  subject,  it  is  seen  that  the 
initial  vascular  spasm  is  produced  with  very  great 

iAnjel,  Archiv.  fur  Psych,  viii.,  2. 


134  NEURASTHENIA. 

facility  and  rapidity,  but  that  the  volume  of  the 
arm  does  not  remain  stationary  during  the  con- 
tinuance of  intellectual  work;  at  the  end  of  some 
instants  it  increases,  then  diminishes  again,  and 
thus  it  exhibits  a  series  of  oscillations  in  different 
directions.  When  the  brain  work  has  come  to  an 
end,  these  changes  still  continue  for  some  time ; 
the  arteries  do  not  at  once  resume  their  habitual 
tone,  as  always  happens  in  a  healthy  subject. 

The  vaso-motor  system  of  the  neurasthenic  re- 
acts, then,  under  the  slightest  causes;  it  is  irritable 
and  feeble  both  together,  since,  when  the  stimulus 
is  withdrawn,  the  arterial  tonus  is  re-established 
more  slowly  than  is  normal.  Anjel  has  further 
observed  that  causes  apt  to  stimulate  the 
vaso-motor  innervation,  meals  and  the  ingestion 
of  stimulating  liquids  for  example,  lessen  this 
instability,  and  that  on  the  other  hand  the  in- 
stability is  increased  if  the  patient  be  fasting. 

Although  they  are  of  a  rather  different  nature, 
the  experiments  of  Weber l  corroborate  the  facts 
observed  by  Anjel.  This  author,  relying  on  a 
group  of  data  furnished  both  by  clinical  obser- 
vation and  by  experiment,  held  that  the  hyper- 
aesthesias,  the  dysaesthesiae,  the  paraesthesiae,  the 
attacks  of  vertigo,  in  a  word  almost  all  the  symp- 
toms of  nervous  exhaustion,  were  due  to  vaso- 
motor  disorders,  to  alternations  of  spasm  and  con- 
gestion brought  about  in  the  nervous  centres 

1  Weber,  Boston  Med.  Journal,  1888. 


ETIOLOGY.  135 

under  the  influence  of  the  slightest  causes.  He 
proposed  therefore  to  define  neurasthenia  as  a 
vaso-motor  neurosis. 

But,  supposing  Anjel's  opinion  to  be  in  con- 
formity with  the  facts,  it  is  evident  that  his  con- 
ception throws  light  only  on  the  pathological  phy- 
siology of  the  functional  disorders  of  neurasthenia 
and  not  on  the  etiology  of  the  disease  itself.  It 
merely  states  the  problem  under  a  new  form,  and 
does  not  tell  us  what  is  the  precise  reason  of  this 
disorder  of  vaso-motor  innervation  and  how  it 
happens  to  be  brought  about  by  so  many  and 
such  diverse  causes. 

To  sum  up,  none  of  the  pathogenic  theories 
that  we  have  just  indicated  is  altogether  satis- 
factory. These  theories  leave  totally  unaffected 
the  conception  that  is  most  generally  held  to-day, 
namely  that  nervous  exhaustion  has  its  source  in 
a  modification  of  all  the  nerve  centres.  In  what 
does  this  neurosis  essentially  consist  ?  What  are 
the  anatomical  or  chemical  alterations  in  the  ner- 
vous centres  on  which  depend  the  psychical, 
motor,  sensory,  circulatory  and  other  disorders 
that  characterise  it  ?  And  how  do  depressing 
passions,  emotions,  and  overpressure  in  all  its 
forms  come  to  bring  them  into  being  ?  We  do 
not  know.  One  may  suppose  with  Erb  a  delicate 
derangement  of  the  nutrition  of  the  nervous  ele- 
ments ;  with  Beard,  a  want  of  balance  between 
their  union  and  their  separation ;  with  M.  Fere,  a 


136  NEURASTHENIA. 

modification  of  their  power  of  vibration  ;  and  yet 
be  none  the  wiser. 

But  if  we  do  not  know  the  essential  nature  of 
the  nervous  disorder,  we  know  at  least  that  it 
shows  itself  by  a  diminution  of  nervous  energy  in 
the  different  systems  ;  this  energy  is  neither  regu- 
larly distributed  nor  uniformly  sustained. 

Whatever  be  the  cause  of  the  neurasthenic 
state,  whether  it  be  constitutional  or  acquired, 
primitive  or  secondary,  consecutive  to  gastric  dis- 
order, to  an  organic  disease,  or,  what  is  most  com- 
mon, to  a  mental  shock,  it  is  this  enfeeblement  of 
nervous  energy  that  constitutes  it.  And  in  making 
use  of  this  expression  we  employ  it  in  its  most 
general  signification,  which  is  also  its  common 
signification  ;  nervous  energy  is  what  usually  is 
simply  called  energy.  Physiologically  we  have 
very  little  knowledge  of  it  ;  we  understand  some- 
thing of  electrical  energy  and  of  thermic  energy, 
but  nervous  energy  is  known  to  us  only  by  its 
manifestations  ;  we  are  almost  totally  ignorant  of 
its  fundamental  causative  conditions.  We  cannot 
even  localise  the  disorders  that  depend  on  it  with 
any  degree  of  precision  ;  thus  we  could  not  say  in 
what  organ  or  organs  the  fatigue  of  the  neuras- 
thenic is  situated.  It  does  not  seem  to  be  in  the 
muscular  fibre  ;  it  is  certainly  not  in  the  nerves  ; 
but  is  it  in  the  end-plates  in  the  muscles1,  in  the 


this  subject  see  Mile.  J.  Jotcyko,  Participation  des  centres 
nerveux  dansles  phenomenes  de  fatigue  musculaire,  in  Annee  psycholo- 
gique,  1900,  and  the  article  by  Z.  Treves,  id.,  1905. 


ETIOLOGY.  137 

cells  of  the  spine,  or  in  those  of  the  cerebral  cortex? 
There  seems  to  be  no  doubt  that,  in  large 
part  at  least,  the  ready  exhaustion  of  the  neuras- 
thenic depends  on  the  disorder  of  these  last.  Let 
it  be  carefully  observed,  however,  that  this  does 
not  amount  to  saying  that  the  readiness  of  ex- 
haustion is  a  psychical,  or  at  any  rate  exclusively 
psychical,  phenomenon.1 

This  is  a  point  on  which  it  is  necessary  to  have 
a  clear  understanding,  for  the  hygiene  and  treat- 
ment of  neurasthenia  depend  on  it. 

When  we  speak  of  a  psychical  affection,  we 
generally  understand  a  disorder  of  the  imagina- 
tion, resulting  from  a  notion  or  belief  that  is 
impressed  on  the  mind.  In  such  cases  there  are 
sometimes  erroneous  interpretations,  as  in  melan- 
cholies or  those  with  delusions  of  persecution, 
and  sometimes  mental  representations  of  diseases, 
as  in  hysterics.  One  is  certainly  justified  in  ask- 
ing if  systematised  delusions,  or  the  delusions  of 
melancholia,  or  the  psychical  disorders  of  hysteria, 
are  really  disorders  that  are  primarily  and  funda- 
mentally psychical.  They  certainly  show  them- 
selves, clinically  at  least,  as  such,  whatever  their 
origin  and  their  organic  and  psychological 
causes  may  be.  This  is  not  the  case  with 

1  Dr.  Maurice  de  Fleury,  in  his  very  interesting  work,  Les  grands 
symptomes  neurastheniques,  wrongly  regards  us  as  partisans  of  the 
psychical  nature  of  neurasthenia.  We  are  anxious  to  dispel  this 
misunderstanding,  which  may  have  originated  in  certain  passages 
of  the  first  edition  of  this  work,  in  which  perhaps  we  expressed  our 
opinion  with  insufficient  precision. 


138  NEURASTHENIA. 

neurasthenic  manifestations  ;  here  we  have  to  do 
with  fatigue,  with  exhaustion,  with  diminution  of 
nervous  energy.  Nothing  resembles  the  perman- 
ent and  chronic  condition  of  the  neurasthenic  so 
closely  as  does  the  transient  and  passing  condition 
of  the  man  who  has  incidentally  been  overtaxed 
by  some  excess  of  work  or  of  the  table,  and  by  the 
insomnia  which  often  follows ;  in  both  cases  there 
occur  headache,  and  a  feeling  of  lassitude  and 
of  physical  and  mental  powerlessness,  with 
phenomena  of  gastric  atony ;  these  symptoms  are 
doubtless  more  marked  in  the  former  than  in  the 
latter,  but,  apart  from  the  question  of  degree,  they 
are  identical  in  the  two  cases.  In  such  circum- 
stances imagination,  auto-suggestion,  and  erron- 
eous beliefs  have  nothing  to  do  with  the  causation 
of  the  phenomena.  If  they  do  intervene,  it  is 
secondarily ;  they  then  fix  the  symptoms,  and 
render  them  more  tenacious  and  more  chronic. 

We  have  already  touched  on  this  point  in  con- 
nection with  the  mental  state  of  neurasthenics, 
and  we  shall  return  to  it  again  when  dealing  with 
psychotherapeutic  treatment.  We  shall  show, 
moreover,  that  certain  of  the  phenomena  of 
exhaustion,  amyosthenia  for  example,  may  be 
lessened,  or  even  dispelled,  or  on  the  other 
hand  increased,  under  the  influence  of  mental 
causes;  this  does  not  mean  that  they  are 
"  imaginary,"  but  that  they  are  influenced  by 
stimulating  agencies,  among  which  mental 


ETIOLOGY.  139 

agencies  hold  an  important  place.  I  do  not 
believe,  any  more  than  does  Maurice  de  Fleury,  in 
"  the  pure  and  simple  subjective  nature  of  the 
"  sensation  of  fatigue  in  true  neurasthenics  " ; 
on  the  contrary,  I  think  with  him  that  this 
"  sensation  of  fatigue,  this  feeling  of  heaviness  in 
"  the  body,  this  need  of  making  efforts  in  order 
"to  walk,  to  go  upstairs,  or  to  stand  up,  this 
"  emptiness  in  the  head,  which  gives  the  impres- 
"  sion  that  one  is  about  to  faint,  but  which  never 
"  goes  so  far,  this  distressing  need  of  recruiting 
"  one's  strength,  this  whole  group  of  symptoms 
"  that  characterises  nervous  exhaustion,  all  these 
"  obey  fixed  laws  which  are  laws  of  mechanics." 
This  does  not  prevent  me,  however,  from  holding 
that  these  patients  may  grow  habituated  to  their 
feelings,  and,  as  a  result  of  this  habit,  which 
becomes  a  sort  of  auto-suggestion,  they  may,  at 
any  given  moment,  mingle  "  a  good  deal  of  imagin- 
"  ation  with  their  feeling  of  lassitude  " ;  traumatic 
neurasthenics  are  a  proof  of  this. 

But,  in  my  opinion,  we  should  misunderstand 
neurasthenia  and  neurasthenics  if  we  considered 
only  these  secondary  auto-suggestions,  and  if  we 
referred  all  the  symptoms  to  them.  We  should 
then  be  subordinating  the  constant  to  the  inci- 
dental, the  primitive  to  the  secondary,  the  princi- 
pal to  the  accessory.  I  willingly  admit,  with 
Dubois  (of  Berne),  that  when  one  analyses  the 
fatigue  of  a  neurasthenic,  one  can  often  discover 


140  NEURASTHENIA. 

"  a  thick  coating  of  auto-suggestion  of  fatigue 
"  round  a  nucleus  of  true  fatigue."  But  I  cannot 
agree  with  him  that  as  a  rule  the  coating  is  as 
"  enormous,"  and  the  nucleus  as  "imperceptible  " 
as  he  supposes. 

Neurasthenia  is  not  a  disease  due  to  auto-sug- 
gestion, like  hysteria,  or  at  least  it  is  only  second- 
arily so ;  it  is  above  all  a  disorder  of  the  energy. 


PART  V. 
PROPHYLAXIS. 

CHAPTER  I. 
GENERALITIES. 

Prophylaxis,  looked  at  as  a  whole,  pursues  a 
double  end :  it  aims  in  the  first  place  at  removing 
the  generating  causes  of  diseases,  and  in  the 
second  place,  if  these  causes  are  inevitable  (as  is 
notably  the  case  with  established  hereditary  de- 
fects), at  placing  the  subjects  exposed  to  their 
noxious  influence  in  a  state  to  resist  them.  .When 
studying  the  causes  of  neurasthenia,  we  saw  how 
important  was  the  part  played  by  morbid  heredity 
in  the  development  of  that  affection ;  we  were  led 
to  recognise  that  neuro- arthritic  heredity  is 
able  by  itself  to  engender  the  neurosis,  but  that  it 
most  often  acts  as  a  predisposing  cause,  by 
bringing  about  in  those  subjected  to  its  influence 
that  inborn  debility  of  the  nervous  system  which 
leaves  them  without  defence  against  the  multiple 
causes  of  the  disease.  The  first  task  to  be  fulfilled 
in  the  preventive  treatment  of  neurasthenia  is  thus 
quite  naturally  sketched  out.  It  consists  in 


142  NEURASTHENIA. 

safe-guarding  the  future  of  children  born  of 
neuropathic  or  arthritic  parents,  by  repressing 
their  hereditary  tendencies  and  strengthening  as 
far  as  possible  the  energy  and  resistance  of  their 
nervous  centres.  To  attain  this  end  nothing  less 
is  needed  than  the  putting  in  practice,  methodi- 
cally and  patiently,  of  all  the  means  at  the  dis- 
posal of  hygiene,  and  that  during  the  whole  of 
the  period  of  development,  from  infancy  to  adult 
age.  To  state  precisely  the  details  of  such  a 
programme  is  to  set  forth  the  regimen  of  physical 
and  moral  education  that  is  appropriate  to  children 
burdened  with  hereditary  defects,  or  congenitally 
predisposed  to  nervous  exhaustion. 

On  the  very  threshold  of  this  study  we  are  met 
by  a  fundamental  question.  Is  it  certain  that 
education  is  able  to  repress  congenital  morbid 
tendencies,  to  modify  profoundly  in  the  individual 
the  temperament,  the  propensities,  and  the  ner- 
vous constitution  that  he  has  inherited  from  his 
forefathers  ?  On  this  point  scientists  and  philoso- 
phers have  put  forth  opinions  that  are  very  dis- 
similar and  even  absolutely  contradictory.  It  is 
well  known  how  the  reforming  and  plastic  power 
attributed  to  education  was  exaggerated  in  the 
18th  century ;  some  went  so  far  as  to  ask  ingenu- 
ously, with  Helvetius,  if  talent,  like  virtue,  could 
not  be  taught,  and  if  the  differences  that  exist 
between  men  did  not  proceed  solely  from  differ- 
ences in  the  surroundings  and  in  the  education 


GENERALITIES.  143 

received.  In  our  days,  after  the  observations  that 
have  been  made  relative  to  the  effects  of  heredity, 
there  is  rather  a  tendency  to  adopt  the  contrary 
belief.  Many  think  with  Herbert  Spencer1  that 
education  is  useless,  or  almost  powerless,  that 
human  evolution  is  always  and  inevitably  ruled  by 
heredity,  that  the  moral  destiny  of  the  man  is 
contained  in  the  foetus,  and  that  madmen  and 
persons  of  unbalanced  mind  are,  like  poets,  born 
not  made.  According  to  this  extreme  doctrine 
then,  it  seems  that  the  nervous  defect,  once  im- 
planted in  the  family,  must  unavoidably  be  trans- 
mitted to  all  the  descendants,  producing  either 
moral  insanity  or  diseases  of  the  nervous  system, 
or  some  other  form  of  that  impoverished  condition 
of  the  body,  due  to  excess  of  disassimilation  over 
assimilation,  which  has  been  called  physiological 
misery,  a  condition  which  will  end  one  day  in 
sterility,  and  thereby  in  the  extinction  of  the 
family.  This  modern  conception,  which  accords 
to  heredity  a  power  at  least  equal  to  that  ascribed 
by  ancient  poets  to  Fate,  is  assuredly  excessive. 
The  antinomy  that  exists  between  the  power 
attributed  by  certain  thinkers  to  education,  and 
that  attributed  by  others  to  heredity,  does  not 
correspond  with  the  facts  ;  between  the  extreme 
views  there  is  place  for  an  intermediate  opinion 
more  conformable  to  the  reality  of  things.  It  is 

1  Mr.  Spencer  held  that  "  imperfections  of  nature  may  be 
diminished  by  wise  management."  Education,  stereotyped  edition, 
p.  96, — Trans. 


144  NEURASTHENIA. 

certain  that  the  vices  of  constitution  accumu- 
lated in  some  families  may  act  with  a  sort  of 
united  energy,  and  produce  irresistible  outbreaks 
in  the  progeny.  But  hereditary  influence  does 
not  always  act  so  powerfully,  and  this  is  unques- 
tionably the  most  frequent  case.  It  is  then  that 
education  may  intervene  efficaciously;  it  suc- 
ceeds in  giving  birth  to  artificial  instincts  capable 
of  balancing  the  hereditary  instincts,  and  even 
of  suppressing  them ;  in  short,  of  substituting  for 
innate  ancestral  habit  an  acquired  individual 
habit. 

The  education  of  children  with  a  hereditary 
neurotic  predisposition  should  pursue  a  triple  end  : 

(1)  to  develop  harmoniously  all  the  capacities  of 
the  individual,  and  more  particularly  the  capacities 
special  to  each,  but  in  such  a  degree  as  not  to 
injure  the  general  equilibrium  of  the  organism ; 

(2)  to  keep  down  any  hereditary  tendencies  that 
may  disorder  the  physical  and  moral  equilibrium ; 

(3)  to  strengthen  the  energy  and  the  physiologi- 
cal power  of  resistance  of  the  nervous  system. 

A  good  method  of  education  should  tend  first  of 
all  to  insure  the  development  of  the  strength  and 
of  what  is  called  physical  health.  That  is  the 
first  requisite,  since  physical  health  is  the  essen- 
tial condition,  or,  if  the  expression  be  preferred, 
the  basis  of  intellectual  health.  After  physical 
development  comes  'moral  development.  Moral 
education,  in  fact,  possesses  a  far  more  powerful 


GENERALITIES.  145 

action  than  mere  instruction  as  a  means  of  recti- 
fying morbid  hereditary  tendencies.  It  is  much 
more  fitted  than  intellectual  education,  in  the 
proper  sense  of  the  word,  to  endow  men  with 
physical  qualities  that  will  make  them  strong  and 
unyielding  in  the  struggle  for  life.  Scientific 
education,  then,  occupies  only  the  lowest  rank, 
and  we  have  not  to  concern  ourselves  with  it  here 
except  in  its  relation  to  hygiene. 

We  shall,  then,  in  this  part  examine  successively 
the  principles  that  should  govern :  (1)  the  physi- 
cal education,  and  (2)  the  moral  education  of 
children  predisposed  by  heredity  to  nervous  ex- 
haustion. 


Neurasthenia  10 


CHAPTER  II. 
PHYSICAL  EDUCATION. 

There  can  be  no  disadvantages  in  developing 
the  strength  of  a  child's  body,  to  whichever  sex  it 
belongs,  or  however  robust  may  be  its  consti- 
tution; physical  health,  in  fact,  is  under  all  cir- 
cumstances a  desirable  possession.  But  it  is  in 
the  case  of  children  sprung  from  a  neuro-arthritic 
stock,  and  hereditarily  predisposed  to  disorders 
of  the  general  nutrition  and  of  the  nervous  sys- 
tem, that  cultivation  of  the  bodily  energy,  such 
as  is  given  by  a  well  thought-out  physical  educa- 
tion, is  especially  necessary.  "  In  primitive 
times,"  says  Spencer,  "when  aggression  and  de- 
"  fence  were  the  leading  social  activities,  bodily 
"vigour  with  its  accompanying  courage  were 
"  the  desiderata ;  and  then  education  was  almost 
"wholly  physical:  mental  cultivation  was  little 
"  cared  for,  and  indeed,  as  in  the  feudal  ages,  was 
"  often  treated  with  contempt.  But  now  that 
" .  .  .  social  success  of  nearly  every  kind  de- 
"  pends  very  much  on  mental  power,  our  educa- 
"  tion  has  become  almost  exclusively  mental. 
"  Instead  of  respecting  the  body  and  ignoring  the 


PHYSICAL   EDUCATION.  147 

"  mind,  we  now  respect  the  mind  and  ignore  the 
"  body."1  Although  in  this  respect  a  happy 
reaction  has  occurred  in  the  course  of  these 
last  years,  Spencer's  criticism  remains  in  great 
measure  thoroughly  well  founded,  and  one  is  still 
warranted  in  saying  that  among  the  educators  of 
youth,  whether  parents  or  masters,  "there  are 
"  few  who  seem  to  understand  that  there  exists 
"  in  the  world  what  may  be  called  physical 
"morality" 

The  physical  education  of  those  predisposed  to 
nervous  exhaustion  involves  the  observance  of  a 
large  number  of  hygienic  measures  dealing  with 
environment,  alimentation,  and  physical  exercises. 
These  we  shall  now  examine  briefly. 

1.  Environment. — Large  towns  form  the  most 
unfavourable  environment  possible  for  the  physi- 
cal development  of  these  subjects.  This  is 
especially  true  for  quite  young  children,  that  is, 
for  those  who  are  passing  through  the  period  of 
growth  that  extends  from  the  third  to  the  twelfth 
year.  In  towns  they  breathe  an  impure  air,  are 
condemned  to  a  relatively  sedentary  life,  have  no 
space  for  outdoor  games ;  the  noise,  the  contact 
of  crowds,  the  social  gatherings  in  which  they 
are  too  often  mingled,  the  thousand  causes  of 
excitement  engendered  by  town  life,  are  so  many 
injurious  conditions  from  which  they  must  at  all 

i  Education  :  Intellectual,  Moral,  and  Physical,  ch.  iv.,  pp.  170,  171 
(cheap  edition). 


148  NEURASTHENIA. 

cost  be  removed.  On  the  other  hand,  the 
country  is  the  ideal  place  of  residence  for  children 
of  this  age :  the  calm  life  of  the  fields,  without 
theatres  or  concerts  or  social  gatherings,  but 
with  pure  air,  simple  food,  incessant  commerce 
with  the  inanimate  and  animate  objects  of  nature 
that  have  so  much  attraction  for  them,  this  life 
has  a  gently  educating  effect,  and  is  the  environ- 
ment that  suits  them  best.  The  country,  says 
Mobius,  is  the  paradise  of  children ;  but  access 
to  it  is  unhappily  forbidden  to  many  of  them. 
Hence  one  should  strive  to  apply  to  the  town-bred 
child  a  system  of  education  that  as  far  as  possible 
realises  the  valuable  hygienic  conditions  that 
country  life  offers  naturally. 

In  studying  the  causes  of  over-pressure  in 
schools,  we  saw  that  the  greater  number  of 
the  nervous  disorders  it  determined  were  much 
more  the  result  of  defective  hygiene  and  physical 
education  than  of  over  brain-pressure  properly  so 
called.  Thus  the  system  of  boarding  schools  is 
especially  evil  for  children  who  are  weakly  or  who 
have  inherited  a  neurotic  predisposition.  Every- 
body knows  the  dangers  that  it  may  present  in 
matters  of  hygiene :  an  unhealthy,  shut-up,  seden- 
tary life,  overcrowding,  as  well  as  strict  rules 
and  a  rigid  arrangement  of  life  that  too  often 
break  the  initiative  of  the  child's  will,  etc.  All 
these  disadvantages  are  serious,  and  if  they  have 
been  in  some  slight  degree  lessened  in  consequence 


PHYSICAL   EDUCATION.  149 

of  the  reforms  recently  introduced  into  the 
scholastic  system,  they  none  the  less  continue 
to  exist  to-day.  The  duration  of  classes  is  exces- 
sive, so  that  the  children  breathe  vitiated  air  in 
the  class-rooms.  The  food  is  sufficient,  but  the 
time  for  meals  is  too  short,  and  in  the  majority 
of  lyceums  the  boys  still  eat  quickly  and  in 
silence.  The  hours  of  sleep  are  too  limited,  and, 
in  consequence  of  the  overburdening  of  pro- 
grammes of  study,  work-time  is  too  long  and  the 
hours  of  rest  are  insufficient  or  badly  portioned 
out.  Since  almost  all  lyceums  are  situated  in  the 
interior  of  towns,  the  fields  and  courts  where  the 
boys  play  are  too  small  and  hardly  allow  of 
"  games  of  pursuit,"  which,  however,  are  the 
healthiest  of  all  exercises  for  children  and 
adolescents.  Finally,  the  morals  of  boarding- 
schools  leave  much  to  be  desired.  M.  Sainte- 
Claire  Deville1  more  than  twenty  years  ago  said 
very  justly  in  this  connection  :  "  Experimental 
"  morality,  if  I  may  be  allowed  the  expression, 
"  can  no  more  be  practised  on  man  than  experi- 
"  mental  physiology ;  but  when  one  works  with 
"  animals,  and,  allowing  always  for  the  human 
"  intellect,  seeks  to  discover  the  physical  causes 
"  of  the  defects  and  vices  of  children,  who  at 
"  certain  periods  of  their  development  come 
"  so  near  to  animals,  I  am  persuaded  that  one 

i  Quoted  by  M.  Guyau,  Education  and  Heredity  (p.  114  of  English 
translation  by  W.  J.  Greenstreet.    London  :  Walter  Scott). 


150  NEURASTHENIA. 

"  may  arrive  at  practical  consequences  of  high 
"  interest.  ...  In  general,  whenever  ani- 
"  mals  of  the  same  sex,  and  especially  of  the 
"  male  sex,  are  brought  together  and  made  to 
"  lead  a  confined  life,  a  great  excitement  of  the 
"  instincts  of  reproduction  is  first  produced,  and 
"  then  a  redoubtable  perversion  of  these  same 
"  instincts.  If,  on  the  contrary,  one  puts  these 
"  animals — which  are  formed  to  live  in  society — 
"either  in  herds  or  in  complete  liberty,  one  at 
"  once  sees  their  normal  characters  assume  the 
"  upper  hand.  .  .  .  What  happens  in  a  herd  of 
"  animals  happens  also  in  a  gathering  of  male 
"  children,  no  matter  of  what  kind  it  be,  or  by 
"  whom  brought  up,  and  even  if  the  children  be 
"  guarded  by  the  strictest  supervision,  both  by 
"  night  and  by  day.  The  most  serious  danger  of 
"  these  vices  for  society  is  the  exaggerated  de- 
"  velopment  of  the  sexual  instincts  between  the 
"  ages  of  twenty  and  thirty,  giving  rise  to  de- 
"  bauchery  and  lubricity.  .  .  ." 

It  is  evident  that  all  these  defects,  all  these 
sins  of  hygiene  that  are  inherent,  so  to  speak,  in 
school-life,  cannot  be  compensated  by  the  "  mutual 
correction  of  character  "  spoken  of  by  partisans 
of  boarding  -  schools.  Consequently  children 
sprung  from  nervous  parents  should  be  forbidden 
to  become  boarders  in  lyceums  and  schools,  and 
should  be  recommended  to  join  as  day-boys.  Un- 
fortunately, if  boarding-schools  be  an  evil  they  are 


PHYSICAL   EDUCATION.  151 

a  necessary  evil,  because  for  many  parents  settled 
far  from  large  towns  they  are  the  only  means  of 
having  their  children  taught.  They  must,  then,  be 
brought  to  perfection.  Moreover  recourse  might 
be  had,  for  children  who  have  inherited  a  neurotic 
predisposition,  to  the  family  system  that  has  long 
been  in  vigour  in  some  English  schools  and  in  the 
majority  of  the  towns  of  Germany.  "  At  present," 
says  M.  Michel  Breal,  who  has  made  a  most  in- 
teresting study  of  these  questions  of  scholastic 
organisation,  "  out  of  every  thousand  boys  attend- 
"  ing  the  German  Gymnasia  there  are  not  a  hun- 
"  dred  who  do  not  live  in  families."  The  children 
are  entrusted  to  respectable  families,  who  give 
them  board  and  lodging  in  return  for  an  often 
modest  payment.  They  have  their  place  at  the 
table  and  at  the  family  hearth,  and  only  go  to  the 
gymnasium  to  receive  instruction  during  class- 
hours.  This  system  formerly  existed  in  France 
too ;  in  his  memories  of  childhood  and  youth, 
Renan  recounts  that  the  school  where  he  received 
his  first  lessons  "  gave  an  education  to  all  the 
"  youth  of  the  little  town  and  the  country  for  six 
"  or  eight  leagues  round.  There  were  few 
"  boarders.  The  young  people,  when  their  parents 
"  did  not  live  in  the  town,  stayed  with  theinhabit- 
"  ants,  several  of  whom  gained  small  amounts  by 
"the  exercise  of  this  hospitality.  .  .  .  This 
"  system  was  that  of  the  middle  ages.  It  is  still 
"that  of  England  and  Germany,  countries  so 


152  NEURASTHENIA. 

"advanced  in  all  that  concerns  educational 
"  questions." 

2.  Physical  Exercises,  Gymnastics. — What 
is  the  best  form  of  gymnastics  for  children  and 
school  boys  ?  Young  children  brought  up  in  the 
country,  when  set  at  liberty  after  the  hours  of 
lessons,  always  find  in  their  neighbourhood  both 
space  to  play  and  attractive  incentives  to  running 
and  all  sorts  of  games.  The  long  walks  over 
broken  country,  the  chases,  in  a  word  the  thousand 
games  that  they  indulge  in,  constitute  a  form  of 
gymnastics  that  is  natural  and  perfect,  and  that 
leaves  nothing  to  be  desired  from  the  hygienic 
point  of  view.  But  what  physical  exercises 
should  be  prescribed  to  schoolboys  in  towns, 
whom  the  overloading  of  programmes  of  study 
condemns  to  an  excessively  sedentary  life  and 
sometimes  to  over  brain-pressure  ?  This  is  a 
hygienic  question  of  the  highest  interest. 

In  1887,  in  the  course  of  the  campaign  that 
was  instituted  against  overpressure  in  schools, 
the  Academy  of  Medicine  was  officially  asked  to 
give  its  opinion  on  the  extent  of  the  evil  and  on 
the  nature  of  the  remedies  that  should  be  applied. 
It  formulated  a  series  of  conclusions  on  the  subject, 
one  of  which  aimed  especially  at  physical  exercises. 
"It  is  imperatively  necessary  to  make  all  school 
"  children  go  through  daily  exercises  of  physical 
"training  proportioned  to  their  age  (walking, 
"  running,  jumping,  military  formations  and 


PHYSICAL   EDUCATION.  153 

"  evolutions,  regulated  and  prescribed  movements, 
"  gymnastics  with  apparatus,  exercises  of  all 
"  kinds,  games  of  strength,  etc.)."  Now  these 
different  exercises  that  the  Academy  recommends 
in  a  lump,  have  not  a  uniform  hygienic  value ; 
they  are  liable  to  produce  very  dissimilar  physio- 
logical effects,  and  one  could  not  without  serious 
disadvantage  prescribe  one  or  other  of  them  in- 
differently to  the  weakly  or  peculiarly  excitable 
children  with  whom  we  are  dealing  here.  It  is 
necessary  to  make  a  choice,  and  to  found  the 
choice  on  reason.  M.  Fernand  Lagrange,1  whose 
competency  in  all  that  relates  to  the  physiology 
of  bodily  exercises  is  universally  recognised,  has 
made  on  this  point  a  series  of  remarks  of  incon- 
testable originality  and  justice.  He  was  certainly 
the  first  to  ask  if  the  methods  of  gymnastics  that 
are  most  in  honour  to-day,  and  notably  those 
approved  by  the  Academy  of  Medicine,  were 
really  those  best  able  to  give  to  the  muscles  of 
school  boys  the  activity  that  they  need,  without 
imposing  a  superaddition  of  fatigue  on  their 
already  overdriven  brains.  Now  M.  F.  Lagrange's 
studies  on  this  subject  led  him  precisely  to 
recognise  that,  in  most  forms  of  exercise  used  at 
lyceums  and  schools,  the  brain  is  obliged  to  take 
part,  and  to  work  as  much  as  the  muscles. 
Fencing  is  a  type  of  the  exercises  that  tire  the 

1  Physiology  of  Bodily  Exercise,    by    Fernand    Lagrange,    M.D., 
International  Scientific  Series. 


154  NEURASTHENIA. 

nervous  centres  much  more  than  the  muscles  of 
the  limbs.  During  the  assault  the  fencer  holds 
himself  constantly  on  the  watch.  Even  when  he 
seems  to  be  at  rest,  his  brain  and  nerves  are  un- 
der the  influence  of  excessive  tension.  His  mind, 
always  awake,  always  in  an  effort  of  sustained 
attention,  watches  for  the  moment  of  attack  or 
riposte.  All  the  muscles  are  kept  in  a  state  of 
latent  excitation,  which  has  ceased  to  be  rest  and 
has  not  yet  become  movement.  One  can  easily 
conceive  that  this  work  of  preliminary  co-ordin- 
ation exacts  a  great  expenditure  of  nerve  force, 
and  "  this  expenditure  sometimes  acquires  still 
"  greater  proportions  in  certain  phases  where  it 
"  is  no  longer  a  simple  movement,  such  as  exten- 
"  sion  of  the  arm  in  a  straight  line,  that  is  to  be 
"  executed,  but  a  series  of  combined  muscular 
"  acts,  as  in  a  counter-parry  followed  by  a  riposte. 
"In  this  case  several  movements  must  at  a  given 
"  moment  follow  one  another  rapidly  and  end  in 
"  a  single  muscular  effort  both  precise  and  sudden. 
"  Thus  a  bout  assumes  quite  the  character  of  an 
"intellectual  operation."  In  other  words,  it  is 
"  head  work  "  that  the  fencer  accomplishes,  and 
those  who  know  from  experience  the  sensation  of 
nervous  fatigue  that  follows  fencing  bouts  will 
agree  that  it  resembles,  not  the  weariness  that 
one  feels  after  a  large  expenditure  of  brute  force, 
but  the  mental  exhaustion  that  succeeds  to  every 
sustained  effort  of  will,  "  as  when,  for  example, 


PHYSICAL   EDUCATION.  155 

"  a  long  struggle  has  been  made  to  repel  the  in- 
"  fluence  of  another's  will,  or  when  the  mind  has 
"  been  kept  powerfully  strained  over  the  solution 
"  of  a  difficult  problem."  When  it  is  pushed  too 
far,  this  nervous  fatigue  may  further  manifest 
itself  by  a  passing  attack  of  excessive  excitement, 
sometimes  accompanied  by  insomnia.  Hence 
fencing  with  foils,  singlestick,  boxing,  and  all  ex- 
ercises of  this  kind  that  imply  a  contest,  are  un- 
suitable to  children  whose  brains  are  active,  and 
especially  to  those  who  are  endowed  with  a  ner- 
vous temperament  and  are  easily  excitable.  They 
antagonise,  it  is  true,  the  effects  of  a  sedentary 
life,  but  they  shake  up  the  nervous  system  too 
violently,  and  instead  of  resting  the  mind  they 
aid  in  producing  over  brain-pressure. 

Gymnastics  with  apparatus,  that  is  to  say  exer- 
cises on  the  trapeze,  the  horizontal  bar,  rings, 
and  parallel  bars,  also  have  serious  disadvantages. 
They  are  usually  unattractive.  They  bring  into 
play  little  beyond  the  muscles  of  the  arms ;  they 
may  give  rise  to  deformities  (excessive  develop- 
ment of  the  muscles  of  the  shoulder  and  arm, 
deviations  of  the  spinal  column,  curving  of  the 
back).  The  movements  that  they  exact  are 
chiefly  difficult  movements,  veritable  feats.  Now 
the  general  effects  of  any  form  of  exercise  are 
proportionate  to  the  expenditure  of  force  that  the 
exercise  requires,  and  not  to  the  difficulties  pre- 
sented by  the  details  of  its  execution.  The 


156  NEURASTHENIA. 

greater  number  of  the  movements  that  boys  in 
lyceums  try  to  execute  during  the  "  gymnastic 
class"  under  the  eye  of  their  monitors,  require 
in  fact  more  skill  than  muscular  effort,  and  their 
difficulty  consists  chiefly  in  finding  out  experi- 
mentally or  methodically  the  muscles  that  must 
be  put  into  action.  One  must  not  then,  in  look- 
ing at  the  matter  from  the  hygienic  point  of  view, 
give  the  preference  to  those  exercises  that  are 
only  skilful,  and  neglect,  as  is  done,  the  exercises 
that  are  really  violent,  but  in  which  muscular 
strength  is  expended  without  there  being  any 
need  to  calculate  laboriously  the  manner  of  its 
use.  Gymnastics,  as  they  are  taught  in  France 
to-day  in  our  educational  establishments,  demand 
real  exertion  of  the  intellect  from  those  who 
practise  them,  and  bring  the  psychical  faculties 
into  play  much  more  than  the  muscular  strength. 
Those  whose  brains  already  expend  enough 
energy  in  the  way  of  intellectual  work  are  not 
those  to  whom  difficult  exercises  are  suited. 

We  have  just  seen  what  are  the  bodily  exercises 
that  should  be  eliminated  from  the  programme  of 
physical  education.  Let  us  now  see  what  are 
those  that  should  be  recommended  to  children  and 
young  people  with  a  neurotic  or  arthritic  taint,  to 
those  in  fact  whom  we  have  especially  in  view. 
These  exercises  should  combine  the  various 
characters  that  follow : 

(a).  They  should  be  easy,  or,  in  other  terms, 


PHYSICAL   EDUCATION.  157 

should  not  require  a  long  apprenticeship  and  con- 
sequently sustained  cerebral  tension.  If  they 
do  not  fulfil  this  condition,  they  may  produce 
either  irritability  of  the  nervous  system  or  ex- 
haustion. 

(6).  They  should  require  fairly  intense  muscular 
work,  and  should  put  the  person  who  executes 
them  moderately  out  of  breath.  They  then  promote 
the  development  of  the  thorax  and  the  oxygenation 
of  the  blood,  and  regulate  tissue-change,  these 
being  the  only  useful  effects  of  physical  exercise 
when  it  is  used  to  obviate  the  results  of  a 
sedentary  life  (insufficient  oxygenation,  disorders 
of  metabolism,  etc.). 

(c).  They  should  be  sufficiently  attractive,  and 
should  be  carried  out  as  far  as  possible  in  the 
open  air. 

Now  the  easiest  exercises,  and  those  that  pro- 
duce the  best  results,  are  marches,  walks,  run- 
ning, chasing,  and  the  old  French  games  of 
Prisoners'  Base,  ball,  leap-frog,  skipping  for 
young  girls,  etc.  These  exercises  of  speed 
are  especially  adapted  to  children  who  have 
not  reached  their  fifteenth  year.  After  that  age, 
young  people  are  more  ready  to  devote  themselves 
to  athletic  sports,  which  are  generally  more 
attractive  to  them.  Among  these,  rowing,  which 
is  so  easily  learnt,  and  cycling,  seem  to  us  especi- 
ally useful.  The  apprenticeship  that  they  exact  is 
never  very  long.  Once  they  are  learnt,  they  only 


158  NEURASTHENIA. 

require  rhythmic  and  automatic  movements,  so 
much  so  that,  while  they  produce  "  air-hunger  " 
and  deep  inspirations,  they  allow  of  complete  rest 
to  the  brain.  The  fatigue  that  they  cause  is 
purely  muscular,  and  thus  they  combat  at  once 
the  disadvantages  of  a  sedentary  life  and  those  of 
overpressure  of  the  intellect. 

3.  Hygiene  of  the  Skin. — Hydrotherapeutics. 
From  their  youngest  age  the  children  of  neurotic 
parents  should  be  accustomed  to  hydrotherapeutic 
practices.     Cold  ablutions,  douches,  plunge-baths, 
sea  or  river  bathing,  followed   by  friction,   will 
always  (unless  there  be  special  centra-indications) 
produce   a    beneficial   effect.     The   action,    both 
sedative  and  tonic,  of  hydrotherapeutic  practices 
upon  the  nervous  system  is  so  well  known  that 
we    need   not   insist   longer    on    their   hygienic 
properties. 

4.  Alimentation.  —  It    is    evident    that     the 
majority  of  those  who  have  inherited  a  neurotic 
predisposition  should  by  no  means  be  subjected  to 
a  special  dietary.     We  must  mention,  however, 
that  they  should  be  allowed  only  an  extremely 
moderate  use  of  alcoholic  liquors.   A  special  regu- 
lation of  the  diet   is   necessary   only   for  those 
who  are  the  children  of  parents  suffering  from 
arthritis,  gout  or  lithiasis,  and  who  have  already 
themselves  exhibited  pathological  manifestations 
of  the  same  origin,  (eczema,  tendency  to  obesity, 
etc.) 


CHAPTER  III. 
MORAL  EDUCATION. 

This  part  of  education  is  assuredly  the  most 
important,  and  yet  the  most  neglected.  To  it 
belongs  the  development  in  children  of  that  union 
of  moral  qualities  that  makes  energetic  and  well- 
balanced  characters,  that  is  to  say  characters  able 
firmly  to  resist  the  dissolving  action  of  afflictions 
and  depressing  emotions,  the  real  origin  of  so 
many  cases  of  neurasthenia.  It  alone  can  give 
the  child  a  strong  will,  confidence  in  himself,  a 
firm  judgment,  in  one  word  all  the  attributes  of 
moral  health  and  strength.  Unhappily  it  is  almost 
always  left  to  chance.  Parents  themselves  have 
rarely  an  exact  idea  of  the  aim  of  education, 
especially  when  the  children  are  still  very  young. 
"What,"  says  M.  Guyau  humorously,  "what  is 
"  the  moral  ideal  set  before  the  children  in  most 
"  families  ?  Not  to  be  too  noisy,  not  to  put  the 
"  fingers  in  the  nose  or  mouth,  not  to  help  them- 
"  selves  with  their  hands  at  table,  not  to  walk  in 
"  puddles  when  it  rains,  etc.  To  be  '  good  ' !  For 
"  many  parents  the  *  good  '  child  is  a  little  puppet 
"  that  must  not  move  unless  the  strings  be  pulled." 


160  NEURASTHENIA. 

The  remark  is  just,  and  it  will  be  agreed  that  it  is 
a  loss  of  precious  time  to  devote  a  child's  first 
years  to  such  an  up-bringing;  to  train  it  in  this 
way  is  not  to  educate  it.  One  can  easily  under- 
stand that  in  these  conditions  free  play  is  given 
to  the  evil  instincts  inherited  by  children.  All 
sorts  of  abnormalities  of  the  character,  a  weak 
and  capricious  will,  obstinacy,  selfishness,  liability 
to  impulses  and  to  anger,  etc.,  will  develop  in  them 
all  the  more  that,  being  the  off-spring  of  un- 
balanced, neuropathic  progenitors,  they  will  often 
have  before  their  eyes  the  invariably  contagious 
example  of  the  faults  and  moral  obliquities  of 
their  parents  themselves. 

In  order  to  be  efficacious,  moral  education  must 
be  put  in  exercise  from  the  earliest  years,  during 
that  period  when  the  child's  mind  is  particularly  apt 
to  receive  impressions  from  without  and  to  pre- 
serve the  mark  of  them.  It  is  not  without  reason 
that  the  state  of  a  young  infant  has  been  compared 
to  that  of  a  hypnotised  subject ;  there  is  the  same 
absence  of  ideas  in  the  one  and  in  the  other,  the 
same  domination  by  a  single  idea  (passive  mono- 
ideism).  If  it  be  true  that,  as  has  been  asserted, 
all  children  are  not  hypnotisable,  at  least  they  are 
peculiarly  open  to  suggestion  in  the  waking  state. 
By  this  we  mean  that  they  show  themselves  per- 
fectly docile  to  all  the  influences  of  those  round 
them.  All  that  they  feel,  all  that  they  perceive, 
impresses  their  minds  and  may  become  the 


MORAL   EDUCATION.  161 

starting-point  of  a  habit  that  will  last  perhaps  their 
whole  lives  long.  This  kind  of  suggestion  differs 
from  hypnotic  suggestion  in  many  important 
features  that  it  is  not  our  business  to  define  here, 
but  it  is  liable  to  produce  sensations  and  senti- 
ments, ideas,  volitions,  and  even  acts,  and  by  the 
repetition  of  these  to  create  instincts  and  habits 
in  the  child.  Suggestion  may  constantly  be  em- 
ployed as  a  means  of  moral  education  and  as  a 
powerful  modifier  of  hereditary  tendencies.  In 
any  case  we  believe  that  it  must  be  one  of  the 
great  agents  in  the  moral  education  of  nervously 
predisposed  children,  because  these  are  particu- 
larly impressionable  and  sensitive  to  impulses 
communicated  to  them  by  suggestion.  Suggestion 
has  been  very  justly  defined  as  "  the  introduction 
into  the  mind  of  a  practical  belief  that  works  out 
its  own  fulfilment  "  (Guyau).  It  follows  that  all 
moral  education  must  aim  at  the  following  end : 
to  convince  the  child  that  he  is  capable  of  good 
and  incapable  of  evil,  in  order  to  give  him  the 
power  to  do  good,  inability  to  do  evil ;  and  to  make 
him  believe  that  he  has  a  strong  will,  and  is 
master  of  himself,  in  order  to  impart  to  him  the 
strength,  and  ultimately  the  habit,  to  exert  his 
will  and  to  govern  himself. 

Esteem  shown  in  public  is  one  of  the  most 
powerful  forms  of  suggestion  for  a  moral  purpose. 
To  say  to  children  that  they  are  supposed  to  have 
such  and  such  a  quality  often  leads  them  to  do  all  in 

Neurasthenia.  11 


162  NEURASTHENIA. 

their  power  to  justify  the  good  opinion ;  conse- 
quently it  is  necessary  to  impart  to  them  as  much 
as  possible  an  early  knowledge  of  their  good  ten- 
dencies, to  attribute  to  them  always  the  qualities 
that  one  wishes  them  to  have,  and  to  believe  them 
capable  of  goodness  and  willingness.  On  the 
other  hand  the  educator  must  carefully  avoid 
giving  to  the  child  "  the  formula  of  his  bad 
instincts."  To  say  aloud  in  a  child's  presence 
that  he  is  lazy,  that  he  is  unable  to  do  this  or 
that,  is  often  to  suggest  to  him,  together  with  the 
belief  that  he  is  incapable  of  application,  the  very 
fault  that  one  wishes  to  repress.  For  the  same 
reason  the  worst  interpretation  must  never  be  put 
on  any  culpable  action  that  he  may  commit.  The 
young  child  is  too  unconscious  to  have  a  deliber- 
ately perverse  intention  ;  to  ascribe  to  him  the 
fixed  determination,  the  resolution  to  do  evil,  is 
to  judge  him  unjustly  and  often  to  develop  in  him 
an  evil  instinct,  together  with  the  notion  that  he 
can  deliberately  commit  a  wicked  action.  It  is 
better  in  such  a  case  to  tell  him  that  he  made  a 
mistake,  that  he  did  not  foresee  the  consequences 
to  which  his  action  might  lead,  etc. 

A  child  should  early  be  accustomed  to  have 
confidence  in  himself.  For  this  purpose  all  about 
him  must  encourage  him  and  receive  with  kindli- 
ness whatever  he  does  or  says  out  of  good-will, 
only  giving  him  gently  to  understand,  if  necessary, 
that  he  might  have  done  better  and  been  more 


MORAL   EDUCATION.  163 

successful  if  he  had  followed  this  or  that  other 
course.  It  is  of  the  highest  importance  that 
timidity  should  not  gain  possession  of  him. 
Nothing  is  more  apt  to  deprive  him  of  confidence 
in  himself  than  to  tell  him  brutally  that  he  does  not 
understand,  does  not  know  how,  cannot  do  this  or 
that,  or  to  laugh  at  his  attempts.  "  Man,"  said 
Pascal,  "is  so  made  that,  by  dint  of  being  told 
"  that  he  is  a  fool,  he  believes  it ;  and  by  dint 
"  of  telling  it  to  himself  he  makes  himself 
"  believe  it.  For  man  carries  on  with  himself  an 
"  internal  conversation  that  it  is  important  to 

"  regulate    well "      Now  the  child  in 

this  respect  is  exactly  similar  to  the  man.  His 
educators  then  must  persuade  him  that  he  can 
understand  and  that  he  can  do  this  thing  or 
the  other,  and  must  be  pleased  with  his  slightest 
effort. 

The  child  must,  again,  be  habituated  to  will  and 
to  accomplish  what  he  has  willed,  to  persevere  in 
his  efforts,  in  one  word  to  be  capable.  For  this 
reason  it  is  good  to  set  him  a  task.  But  this  task 
should  for  a  long  time  be  below  his  powers,  and 
should  only  increase  in  proportion  to  their  develop- 
ment. If  this  condition  be  not  fulfilled,  if  the 
child  always  feel  that  he  is  not  able  for  his  work, 
then  the  task  set  him,  instead  of  being  a  salutary 
exercise,  a  training  of  his  will  and  attention,  will 
only  serve  to  convince  him  of  his  powerlessness 
and  to  discourage  him.  Little  by  little  he  will 


164  NEURASTHENIA. 

lose  all  confidence  in  his  abilities  and  will  mis- 
trust himself;  and  this  sentiment,  once  it  has 
grown  up  and  installed  itself  in  his  consciousness, 
may  give  rise  in  him  to  that  moral  paralysis  that 
is  called  aboulia. 

Against  evil  instincts  and  uncontrollable  im- 
pulses the  surest  remedy  is  again  suggestion  by 
precept  and  example.  To  teach  children  to  be  firm, 
one  must  be  firm  in  dealing  with  them.  They 
admire  strength  of  will  in  others  just  as  they 
admire  physical  strength,  and,  as  they  always 
model  themselves  on  those  about  them,  to  give 
them  an  example  of  firmness  and  to  have  a  strong 
will,  is  to  make  them  firm  also  and  to  strengthen 
their  will.  But  it  is  absolutely  necessary  to  make 
them  understand  once  for  all  that  the  commands 
given  to  them  are  reasonable  and  have  no  other 
object  than  their  good,  and  thus  to  accustom 
them  to  obey  confidently  when  the  reason  of  the 
actions  commanded  escapes  their  comprehension. 
To  obtain  from  them  this  habitual  readiness  to 
obey,  it  is  necessary  that  the  educators,  whoever 
they  may  be,  should  establish  their  authority. 
Now  this  is  not  a  matter  of  crushing  the  children's 
will  by  breaking  it  in,  so  to  speak,  mechanically, 
but  rather  of  directing  it,  taking  care  always  that 
it  does  not  enter  into  conflict  with  the  will  of  the 
parents. 

In  what  then  does  authority  really  consist,  and 
how  must  it  be  exerted  ?  In  his  excellent  book 


MORAL   EDUCATION.  165 

on  "  Heredity  and  Education,"  Guyau  has  given 
a  happy  definition  of  it.  "  Authority,"  he  writes, 
"  is  made  up  of  three  elements  :  (1)  affection  and 
"  moral  respect ;  (2)  the  habit  of  submission,  a 
"  habit  springing  from  the  exercise  of  the  quality; 
"  (3)  fear.  Each  of  these  elements  enters  into  the 
"  sentiment  of  authority,  but  the  others  must  be 
"  subordinated  to  affection.  Affectionate  feeling 
* '  takes  away  the  necessity  for  harsh  authority 
"  and  chastisement."  The  child  that  needs  chas- 
tisement is  wanting  in  affection,  and  it  is  by  the 
love  one  bears  him  that  one  may  arouse  in  him  a 
return  of  that  sentiment.  Moreover,  the  affection 
of  his  parents  must  always  be  a  reward  that  he 
must  earn  by  good  conduct,  a  reward  superior 
to  all  others.  Respect  is  merely  a  form  of  this 
sentiment.  There  remains  fear.  The  chastise- 
ment that  inspires  it  must  always  be  just,  and 
should  only  be  used  as  an  exceptional  sanction, 
exclusively  reserved  for  grave  faults,  for  open 
rebellion.  It  is  its  exceptional  character  that 
makes  chastisement  efficacious.  To  multiply 
reprimands  and  corrections  is  to  deprive  them  of 
all  reforming  power  over  the  child's  mind.  If  he 
do  wrong  again  a  short  time  after  having  been 
punished,  the  best  plan  is  to  shut  the  eyes,  to 
appear  not  to  see  the  bad  intention,  to  change 
one's  manner  abruptly,  to  distract  the  child,  "  and 
thus  render  the  misdeed  abortive."  Chastisement, 
whether  it  be  bodily  or  other,  must  always  be 


166  NEURASTHENIA. 

administered  without  roughness  or  anger,  so 
that  the  child  may  not  take  example  from  its 
master  to  show  itself  rough  and  irascible  in  its 
turn.  Finally,  care  must  be  taken  to  give  the 
punishment  a  moral  aspect,  for  it  is  not  the  fear  of 
chastisement  in  itself  that  must  be  aroused  in 
the  child's  mind,  but  rather  a  moral  regret  for 
having  deserved  it. 

Bad  temper,  melancholy,  pessimism,  and  selfish- 
ness, are  perversions  of  character  that  are  fre- 
quent in  neuropaths  and  in  those  of  unbalanced 
mind.  The  germ  of  these  unsociable  sentiments 
is  found  in  certain  mental  states  of  the  child 
which  appear  to  have  little  gravity,  but  which 
must  be  repressed  in  good  time. 

Sulking,  for  example,  is  only  a  first  manifesta- 
tion of  unsociableness.  The  child  who  sulks  takes 
pleasure  in  displeasing  those  who  thwart  him, 
and  satisfies  his  self-esteem  by  resisting  the  will 
of  others  without  acknowledging  himself  van- 
quished. By  allowing  him  to  acquire  the  habit 
of  sulking  after  every  reprimand,  one  gives  him 
the  habit  of  continuing  in  the  fault  committed 
without  any  attempt  at  making  amends  for  it, 
and  consequently  without  remorse.  Children 
then  must  be  accustomed  to  be  quickly  reconciled 
with  the  person  who  has  scolded  them.  They 
thus  form  the  habit  of  being  unable  to  bear  the 
idea  of  "  being  cross  "  with  any  one,  of  wishing 
to  make  amends  for  their  faults,  which  is  one 


MORAL   EDUCATION.  167 

form  of  active  remorse,  and  of  waiting  eagerly 
for  the  word  that  reconciles  and  brings  peace 
to  the  heart. 

Bad  temper  is  very  often  the  result  of  educa- 
tion. The  child  who  is  overwhelmed  with  inces- 
sant reproaches,  or  who  is  thwarted  uselessly  and 
on  all  occasions,  retires  within  himself  and  takes 
to  brooding  over  his  woes  and  disappointments ; 
little  by  little  he  accustoms  himself  to  melan- 
choly, and  later  on  he  will  be  more  inclined  than 
others  to  pessimism,  moral  depression,  and  dis- 
couragement. 

There  is  another  mental  perversion  that  it  is 
important  to  combat  from  infancy ;  that  is  vanity, 
which  contains  in  germ  the  exclusive  preoccu- 
pation with  self  that  is  so  common  among  hypo- 
chondriacs and  hereditary  neurasthenics. 

Excessive  emotionalism  is  a  defect  common  to 
the  greater  number  of  children  sprung  from  a 
neuropathic  stock,  and  its  development  must  at 
all  costs  be  repressed.  Emotionalism  most  cer- 
tainly depends  on  an  innate  disposition  of  the 
nervous  system,  which  causes  the  least  moral 
shock,  the  slightest  contrariety,  to  provoke  in  the 
nerve  centres  a  painful  reaction  that  is  diffused 
through  all  the  organs,  and  produces  in  them  that 
complex  group  of  disagreeable  impressions  that 
constitutes  emotion.  But  this,  again,  is  a  tend- 
ency which  may  be  kept  down  and  even  extin- 
guished by  a  wisely-conducted  physical  and  moral 


168  NEURASTHENIA. 

education,  just  as  it  is  cultivated  and  naturally 
increased  if  that  obstacle  to  it  be  neglected.  To 
attain  this  end,  various  measures  must  be  put  into 
operation.  The  education  of  the  will,  by  strength- 
ening the  cerebral  centres  that  control  reflex  ac- 
tions, contributes  a  large  share ;  physical  educa- 
tion, bodily  exercises,  and  hydrotherapeutic  prac- 
tices give  tone  to  the  nervous  system  and  also 
lessen  its  sensitiveness.  On  the  other  hand 
nothing  is  more  pernicious  than  the  terrifying 
stories,  the  fantastic  descriptions  of  monstrous 
beasts,  that  are  inflicted  on  the  imagination  of 
children.  These  cultivate  in  them  the  sentiment 
of  fear,  and  often  nocturnal  terrors ;  the  hallu- 
cinations of  the  half-sleeping  state,  that  agitate 
them  in  the  early  hours  of  the  night,  have  no 
other  origin.  Nothing  is  more  contagious  than 
an  emotional  state,  and  therefore  it  is  important 
that  when  they  reach  a  more  advanced  age  they 
should  be  carefully  kept  away  from  witnessing 
the  emotions  of  their  parents  or  teachers,  who 
should  never  show  them  the  spectacle  of  their 
own  distress,  fears,  or  impulses  of  anger.  In 
other  words,  children  should  not  be  associated 
early  with  the  life  of  those  about  them.  They 
must  be  removed  from  all  surroundings  where 
causes  of  excitement  and  agitation  abound.  In 
towns  they  should  be  forbidden  to  attend  parties, 
dramatic  spectacles,  or  the  theatre,  till  the  twelfth 
or  fifteenth  year  of  their  age. 


MORAL   EDUCATION.  169 

At  the  epoch  of  puberty,  those  who  are 
predestined  by  their  hereditary  taints  to  morbid 
impulses  of  all  sorts  should  be  the  object  of  particu- 
larly attentive  supervision.  The  awaking  of 
sexual  instinct  and  desires  throws  the  equilibrium 
of  their  nervous  system  into  profound  disorder. 
The  majority  of  them  give  themselves  up  to  ex- 
cessive practices  of  onanism,  and  that,  as  we  saw 
in  studying  the  causes  of  neurasthenia,  is  often  a 
powerful  factor  in  its  production.  Children 
brought  up  in  the  midst  of  the  family  may  be 
preserved  from  this  perversion  if  care  be  taken, 
on  the  approach  of  puberty,  to  turn  them  away 
from  all  that  may  attract  their  attention  to  the 
sexual  functions,  or  prove  a  cause  of  genital  ex- 
citement. But  in  boarding-schools  these  preven- 
tive measures  cannot  be  carried  out,  and  the  best 
plan  is  to  attenuate  as  far  as  possible  an  evil  that 
cannot  be  prevented.  This  may  be  managed  by  a 
rigorous  supervision  at  all  moments,  and  by  putting 
into  operation  the  invariably  sedative  action  of 
physical  exercises  and  hydrotherapeutic  practices. 
Finally,  it  is  good  for  hereditarily  predisposed  sub- 
jects, when  they  reach  adult  age,  to  take  to  a  pro- 
fession. For  every  profession,  when  once  adopted, 
corresponds  from  the  moral  point  of  view  to  a 
group  of  constant  and  co-ordinate  suggestions 
that  impel  us  to  act  in  conformity  with  a  ruling 
idea,  and  impose  on  us  at  any  moment,  in  despite 
of  our  individual  passions  or  hereditary  inclinations, 


170  NEURASTHENIA. 

a  rule  of  conduct  conformable  to  our   calling.1 

1Goodhart  (On  Common  Neuroses — London,  1894)  believes  that 
certain  professions  seem  to  develop  neurotic  tendencies ;  and 
notably,  he  says,  the  clerical,  the  medical,  and  that  of  dealing 
in  stocks.  But  see  the  table  on  p.  23.  It  is  evident  that  fixed 
hours  of  work  and  a  fixed  salary  are  especially  advantageous 
features  in  an  occupation  in  the  case  of  neurotic  subjects. — Trans. 


CHAPTER  IV. 
PROPHYLAXIS  IN  ADULTS. 

The  preventive  measures  that  are  applicable  to 
adults  follow  naturally  from  the  study  of  the  ex- 
citing or  determining  causes  of  nervous  exhaustion. 
We  cannot  enumerate  them  here,  because  they 
form  part  of  the  rules  of  Individual  and  Profes- 
sional Hygiene  in  general.  And,  besides,  the 
great  causes  of  neurasthenia  are  almost  unavoid- 
able. How  are  we  to  prevent  moral  overpressure, 
the  origin  of  so  many  cases  of  nervous  exhaustion  ? 
This  overpressure  has  become  to  some  extent  a 
necessary  condition  of  the  life  of  our  epoch.  The 
knowledge  of  the  higher  causes  that  inflict  it  on 
the  present  generation,  the  study  of  the  means 
adapted  to  lessen  it  or  prevent  its  existence,  these 
clearly  are  not  under  the  control  of  hygiene  in  the 
strict  sense  of  the  word.  They  belong  much 
rather  to  the  province  of  sociology.  Herbert 
Spencer,  in  his  philosophical  commentaries  on 
the  social  life  of  the  Americans,  seems  to  have 
perceived  with  a  sure  vision  the  profound  causes 
of  this  over-activity,  of  this  existence  at  high 
tension  in  which  the  toiling  classes  of  large 


172  NEURASTHENIA. 

industrial  and  commercial  centres  exhaust 
themselves.  "  Moreover  in  every  circle  I  have  met 
"  men  who  had  themselves  suffered  from  nervous 
"  collapse  due  to  stress  of  business,  or  named 
"  friends  who  had  either  killed  themselves  by 
"  overwork  or  had  been  permanently  incapacitated, 
"  or  had  wasted  long  periods  in  endeavours  to 
"  recover  health.  .  .  .  Immense  injury  is  being 
"  done  by  this  high-pressure  life — the  physique  is 
"  being  undermined.  .  .  .  Exclusive  devotion  to 
"  work  has  the  result  that  amusements  cease  to 
"  please ;  and  when  relaxation  becomes  imperative, 
"  life  becomes  dreary  from  lack  of  its  sole  interest 
"  — the  interest  in  business.  ...  It  is  recognised 
"  that  getting  on  devours  nearly  all  other  satis- 
"  faction — there  is  not  that  abandonment  to  the 
"  moment  which  is  requisite  for  full  enjoyment ; 
"  and  this  abandonment  is  prevented  by  the  ever- 
"  present  sense  of  multitudinous  responsibilities. 
"  So  that  beyond  the  serious  physical  mischief 
"  caused  by  overwork  .  .  .  there  is  the  further 
"  mischief  that  it  destroys  what  value  there  would 
"  otherwise  be  in  the  leisure  part  of  life."  After 
analysing  the  social  and  political  causes  of  this 
excessive  activity,  this  desperate  pursuit  of  fortune, 
Spencer  declares  that  we  need  to  revise  our  ideal 
of  life,  and  that  if  we  look  into  the  past  we  find 
that  the  ideal  has  varied  with  varying  social 
conditions.  Everyone  knows  that  to  be  a  victori- 
ous warrior  was  the  loftiest  aim  among  the 


PROPHYLAXIS   IN   ADULTS.         173 

celebrated  nations  of  the  past,  as  it  still  is  among 
many  peoples  of  to-day.  In  those  times  man's 
true  business  was  to  fight.  We  have  changed  all 
that  in  our  modern  societies.  With  the  develop- 
ment of  industrial  life,  "  the  duty  to  work  has 
taken  the  place  of  the  duty  to  fight." 

Will  this  modern  ideal  survive  in  the  future  ? 
We  may  reasonably  doubt  it.  It  is  appropriate  to 
those  ages  in  which  the  conquest  of  the  earth 
and  the  subjection  of  natural  forces  to  man's  use 
are  the  predominating  need.  "  But  hereafter," 
writes  Spencer,  "  when  both  these  ends  have  in 
"  the  main  been  achieved,  the  ideal  formed  will 
"  probably  differ  considerably  from  the  present 
"  one.  ...  I  should  have  liked  to  contend  that 
"  life  is  not  for  learning,  nor  is  life  for  working, 
"  but  learning  and  working  are  for  life.  .  .  .  We 
"  may  trace  everywhere  in  human  affairs  a  ten- 
"  dency  to  transform  the  means  into  the  end.  All 
"  see  that  the  miser  does  this  when,  making  the 
"  accumulation  of  money  his  sole  satisfaction,  he 
"  forgets  that  money  is  of  value  only  to  purchase 
"satisfactions.  But  it  is  less  commonly  seen  that 
"  the  like  is  true  of  the  work  by  which  the  money 
"  is  accumulated,  that  industry  too,  bodily  or 
"  mental,  is  but  a  means,  and  that  it  is  as  irration- 
"  al  to  pursue  it,  to  the  exclusion  of  that  complete 
"  living  it  subserves,  as  it  is  for  the  miser  to 
"  accumulate  money  and  make  no  use  of  it.  Here- 
"  after,  when  this  age  of  active  material  progress 


174  NEURASTHENIA. 

"  has  yielded  mankind  its  benefits,  there  will,  I 
"  think,  come  a  better  adjustment  of  labour  and 
"  enjoyment.  ...  In  brief,  I  may  say  that  we 
"  have  had  somewhat  too  much  of  the  gospel  of 
"  *  work.'  It  is  time  to  preach  the  gospel  of 
"relaxation."1 

1  Spencer,  Speech  in   New  York,   Nov.   9,  1882.    See   Essays, 
vol.  III.,  pp.  482-486. 


PART   VI. 
TREATMENT. 

CHAPTER  I. 
GENERALITIES. 

In  the  last  part,  which  was  devoted  to  prophy- 
laxis, we  had  to  confine  ourselves  to  indicating 
the  principles  which  we  believe  should  govern  the 
physical  and  moral  education  of  those  predisposed 
by  heredity  to  nervous  asthenia.  It  is  indeed  in  a 
good  education  that  the  surest  prophylaxis  of  ner- 
vous exhaustion  seems  to  us  to  lie.  Adult  age, 
which  is  that  of  the  struggle  for  life,  is  inevitably 
exposed  to  the  multiple  and  diverse  influences 
that  produce  neurasthenic  states ;  cares,  passions, 
reverses,  and  sicknesses  are  so  many  causes  which 
the  best  prophylactic  code  cannot  suppress ;  the 
preventive  rules  that  might  be  formulated  against 
them  would  have  no  practical  value,  because  they 
make  an  integral  part  of  life  itself.  Thus  the  only 
course  possible  is  to  prepare  men  by  a  vigorous 
education  to  resist  their  onset  victoriously. 

We    must    now  study    the   different   hygienic 


176  NEURASTHENIA. 

methods  that  may  be  put  into  operation  to  cure 
confirmed  neurasthenic  states.  Experience  has 
shown  that  the  best  treatment  of  neurasthenia  is 
that  which  consists  in  a  wise  regulation  of  the 
patient's  hygiene.  In  the  very  great  majority  of 
cases,  indeed,  recourse  should  be  had  almost  ex- 
clusively to  the  methodically  combined  application 
of  the  different  hygienic  agents  at  our  disposal ; 
the  part  played  by  pharmaceutical  medication 
should  here  be  altogether  secondary.  We  shall 
show,  moreover,  that  the  employment  of  drugs  is 
more  often  injurious  than  useful,  that  they  may, 
to  say  the  least,  counteract  the  effects  of  hygienic 
therapeutics,  and  we  shall  examine  the  degree  in 
which  they  are  capable  of  aiding  the  curative  in- 
fluence of  this  last,  which  must  always  constitute 
the  essential  and  fundamental  part  of  the  treat- 
ment. 

The  causes  of  neurasthenia  and  the  clinical 
forms  that  it  may  assume  are,  as  we  have  seen, 
extremely  numerous,  and  it  is  clear  that  the 
details  of  the  hygienic  rules  suited  to  each  par- 
ticular case  are  themselves  variable,  and  that  they 
may  differ  appreciably  from  one  patient  to  another. 
Consequently,  as  we  cannot  repeat  too  often,  it  is 
indispensable  to  ascertain  precisely,  by  a  thorough 
inquiry,  the  real  causes  of  the  affection  in  each 
patient,  the  functional  disorders  by  which  it  mani- 
fests itself,  and  the  degree  of  importance  of  each. 
Having  said  this,  it  is  evident  that  we  cannot  here 


GENERALITIES.  177 

point  out  in  detail  all  the  variations  of  treatment 
required  by  the  diversity  of  clinical  cases.  We  shall 
confine  ourselves  to  setting  forth :  (1)  The  general 
hygiene  of  neurasthenics,  keeping  more  especially 
in  view  cerebro-spinal  neurasthenia,  which  really 
answers  to  the  commonest  type  of  the  neurosis ; 
and  (2)  the  special  therapeutical  indications  of 
some  of  its  principal  clinical  forms. 

In  the  following  chapters,  which  deal  with  the 
general  hygiene  of  neurasthenics,  we  shall  investi- 
gate successively  what  should  be  the  diet  of  the 
patients,  what  climates  are  more  especially  bene- 
ficial to  them,  what  advantages  they  may  derive 
from  hydrotherapy,  massage,  and  gymnastic  exer- 
cises, and  also  what  must  be  the  moral  hygiene, 
or,  if  the  expression  may  be  used,  the  mental 
dietary  of  this  class  of  subjects. 


Neurasthenia  12 


CHAPTER  II. 

GENERAL  TREATMENT  OF  NEURASTHENICS. 
PSYCHOTHERAPY. 

All  authors  agree  nowadays  in  recognising  the 
importance  of  psychotherapy  in  the  treatment  of 
nervous  asthenia.  And  yet  this  subject  has  been 
almost  invariably  sacrificed  in  treatises  and  mono- 
graphs. We  hold,  with  Striimpel  and  Bouveret,that 
the  moral  action  exerted  on  the  neurasthenic  by  his 
physician  and  his  surroundings,  constitutes  one 
of  the  most  powerful  therapeutic  agents  that  can 
be  employed. 

This  view,  which  we  expressed  in  the  first 
edition  of  this  work,  has  since  then  been  taken  up 
again  and  developed  by  various  authors,1  perhaps 
even  with  some  exaggeration.  Thus  Dubois  (of 
Berne)  has  gone  so  far  as  to  hold  not  only  that 
psychotherapy  is  a  mode  of  treatment  applicable 
to  all  psychoneuroses  without  exception,  an 
opinion  to  which  we  cannot  subscribe,  but  also 
that  its  employment  renders  all  other  treatment 
unnecessary  in  neurasthenia.  We  cannot  associate 

iDubois,  loc.  cit. — Jean   Camus    and   Ph.   Pagniez,   Isolcment  et 
psychotherapic,  with  preface  by  J.  Dejerine.    Paris,  Alcan,  1904. 


PSYCHOTHERAPY.  179 

ourselves  with  this  exclusive  view,  to  which, 
moreover,  Dubois  himself,  and  Dejerine,  who  has 
adopted  it,  are  not  strictly  faithful,  since  they 
accompany  psychotherapy  by  rest  and  diet. 

It  seems  to  us  that  there  is  nothing  so  injurious 
in  therapeutics  as  a  system.  Psychotherapy  is 
not  a  panacea  applicable  to  everything,  any  more 
than  is  electricity  or  shower-baths,  and  one 
would  only  do  it  harm  if  one  tried  to  employ  it 
in  one  unchanging  form  in  all  cases  of  the  psycho- 
neuroses  without  distinction.  We  insisted  above 
on  the  necessity  of  first  forming  an  exact  differ- 
ential diagnosis  before  beginning  the  treatment  of 
a  nervous  affection.  A  psychical  treatment  which 
succeeds  marvellously  in  one  of  these  affections 
may  fail  totally  in  another.  Melancholia  is  not 
treated  like  the  folic  du  doute,  nor  the  latter  like 
hysteria,  nor  is  hysteria  treated  like  neurasthenia, 
though  it  is  akin  to  it  in  certain  directions,  or 
at  least  is  often  associated  with  it. 

Moreover,  it  is  almost  a  commonplace  truth  to 
say  that  the  same  treatment  is  not  applicable  to 
all  forms  of  one  single  affection,  and,  as  regards 
neurasthenia  in  especial,  it  is  indispensable  to 
adapt  the  methods  of  treatment,  or  at  least  their 
mode  of  application,  to  the  peculiarities  of  each 
individual  case. 

Having  made  these  reservations,  we  must  give 
it  as  our  opinion  that,  next  to  hysteria,  neuras- 
thenia is  the  nervous  affection  in  which 


180  NEURASTHENIA. 

psychotherapeutics  render  the  greatest  services. 

It  is  not  that,  like  some  authors,  we  consider 
the  complaint  as  purely  mental.  We  have  defined 
it  as  an  exhaustion  disease,  and  we  think  that  it 
consists  of  an  enfeeblement  of  nerve  force.  But 
if  neurasthenia  is  far  from  being  an  exclusively,  or 
even  principally,  a  psychical  disease,  it  is  at  least  a 
disease  in  the  origin  and  course  of  which  psychical 
processes  play  a  multiple  and  important  part. 
These  occupy  a  preponderating  position  in  its 
etiology,  because,  as  we  have  already  indicated, 
the  commonest  causes  of  neurasthenia  are  of  a 
mental  nature — emotions,  cares,  disappointments, 
business  worries^  They  occupy  also  a  large  place 
in  its  symptomatology,  first,  because  exhaustion 
affects  the  psychical  functions  properly  so-called 
(memory,  will,  emotionalism)  in  the  same  way  as 
the  other  nervous  functions,  secondly  and  princi- 
pally because  they  fix  in  the  mind  certain  images 
which  at  once  give  rise  to  disorders  that  are 
permanent  and  durable,  even  when  the  cause  that 
initiated  them  has  disappeared.  A  local  phe- 
nomenon which  at  the  outset  depended  on  pure 
nervous  asthenia  (such  as  gastro-intestinal  atony, 
localised  amyosthenia,  topoalgia,  etc.),  may  in  the 
long  run,  when  a  habit  has  been  acquired,  form  an 
integral  part  of  the  mental  condition.  Moreover, 
just  as  in  organic  diseases  (as  tabes  or  disseminated 
sclerosis)  symptoms  arising  from  apprehension, 
fear  and  auto-suggestion  are  often  added  by  the 


PSYCHOTHERAPY.  181 

mind  to  those  that  depend  directly  on  the  lesion, 
so  in  neurasthenia  the  mind  enlarges  the  picture 
by  adding  new  phenomena  to  those  due  exclusively 
to  exhaustion.     Hence  one  can  imagine  that  the 
part  played  by  psychical  processes  in  treatment 
must  not  be  neglected ;   on  the  contrary,   great 
importance  must  be  attached  to  them,  whether 
it  be  that  one   wishes  to  cause  the   disappear- 
ance— by  isolation,  for  example — of  the  sensory 
impressions    or   associations   of   ideas   that    are 
liable    to    recall     the     emotions    and    anxieties 
which  originated  the  complaint,  or  that  one  tries 
to  stimulate  the  failing  energy  of  the   will,   or 
again   that   one  aims,    by    a   sort   of    re-educa- 
tion, at  dispelling  bad  habits  that  have  been  ac- 
quired and  helping  the  mind  to  correct  certain 
erroneous  perceptions.     Such,  as  far  as  neuras- 
thenia is  concerned,  is  the  role  of  psychotherapy. 

When  setting  forth  the  causes  and  symptoms 
of  neurasthenia,  we  endeavoured  to  bring  to  the 
front  the  part  played  by  moral  troubles  and  sor- 
rowful emotions  in  the  etiology  of  the  neurosis, 
and  the  importance  of  the  state  of  mental  depres- 
sion in  which  the  greater  number  of  neurasthenics 
live,  no  matter  what  may  have  been  the  cause 
that  produced  their  malady.  Decay  of  mental 
energy  and  of  will,  tendency  to  discouragement, 
to  melancholy  ideas,  and  to  the  hypochondriacal 
preoccupations  aroused  and  kept  up  by  the 
distressing  sensations  that  torment  them,  such,  as 


182  NEURASTHENIA. 

we  said,  are  the  essential  features  of  the  moral 
state  of  these  patients.  We  rightly  insisted  on 
their  impressionable  natures,  on  the  readiness 
with  which  they  obey  the  various  incitements 
that  come  to  them  either  from  themselves  or  from 
others,  in  one  word  on  their  suggestibility.  They 
are  almost  all  suggestionable  in  the  waking  state, 
though  in  different  degrees.  This  suggestibility 
is  a  direct  consequence  of  the  enfeeblement  of 
their  moral  personality,  and  is  certainly  an  unfor- 
tunate condition,  since  it  delivers  them  over 
almost  defenceless  to  the  usually  depressing 
influence  exerted  on  their  minds  by  their  function- 
al disorders,  and  even  by  the  environment  in 
which  their  illness  developed.  But  on  the  other 
hand  it  enables  the  physician  to  act  beneficially 
on  their  mental  state,  to  cheer  them  morally,  and 
to  restore  their  lost  courage  and  confidence  by 
removing  from  their  minds  the  fears,  the  gloomy 
ideas,  and  the  hypochondriacal  obsessions  which 
gave  rise  to  the  nervous  exhaustion,  or  which 
contribute  largely  to  keep  it  up. 

The  psychical  treatment  of  neurasthenics  does 
not  consist  only  in  the  cheering  moral  influence 
that  the  physician  is  called  upon  to  exert  on  the 
patient  by  his  words  and  attitude.  Independently 
of  this  direct  action  of  the  physician  on  the  patient, 
there  exists  a  whole  group  of  psychical  influences 
whose  therapeutic  value  is  not  less,  and  which 
must  be  well  understood :  we  refer  to  the 


PSYCHOTHERAPY.  183 

suggestions  imparted  to  the  patient's  mind  by  the 
putting  in  action  of  the  various  hygienic  measures 
adopted  in  the  general  treatment  of  nervous  exhaus- 
tion. Isolation,  life  in  the  country  and  in  a  favourable 
climate,  hydrotherapy,  electricity,  all  these  hy- 
gienic and  therapeutic  agents  which  seem  to  be 
directed  solely  to  the  organic  condition  of  the 
patient,  act  also  on  his  mental  state.  We  do  not 
assert  that  these  physical  agents,  such  as  water 
or  electricity  for  example,  owe  their  therapeutic 
effects  exclusively  to  the  suggestive  influence 
that  they  exert  on  the  minds  of  neuropaths ;  but 
it  is  certain  that  that  influence  is  considerable. 
Consequently  we  must  here  consider  in  suc- 
cession : 

1 .  The  psychotherapeutic  action  of  the  different 
hygienic    measures    comprised    in    the    general 
treatment  of  neurasthenia ; 

2.  The  psychotherapeutic  r61e  of  the  physician. 
1.  Psychical  influence  of  the  different  hygienic 

measures  utilised  in  the  general  treatment  of 
neurasthenia  (Indirect  psychotherapy).  —  The 
beneficent  action  exerted  on  the  moral  condition 
of  neurasthenics  by  the  application  of  the  various 
hygienic  measures  that  we  shall  consider  succes- 
sively in  the  following  chapters,  is  incontestable  ; 
it  constitutes  a  valuable  adjunct  to  the  psychical 
treatment  of  this  class  of  invalids.  Isolation,  with- 
drawal from  the  surroundings  in  which  his  neuro- 
pathic state  developed,  residence  in  the  country 


184  NEURASTHENIA. 

or  in  a  special  establishment,  hydrotherapy,  elec- 
tricity, all  these  therapeutic  agents  do  not  only 
influence  the  somatic  state  of  the  patient,  but,  in 
very  dissimilar  ways,  they  also  act  beneficially  on 
his  mental  state.  It  may  even  be  affirmed  that  it 
is  to  this  moral  action  that  they  owe  the  greater 
part  of  their  curative  power. 

When  he  isolates  himself  from  his  family,  and 
withdraws  from  the  surroundings  in  which  his 
neurasthenia  developed,  in  order  to  live  amid 
pleasant  scenery  in  the  country  or  to  instal 
himself  in  a  special  establishment,  the  overdriven 
invalid  immediately  effects  a  reformation  that  is 
particularly  favourable  to  the  re-establishment  of 
his  moral  equilibrium.  He  separates  himself  from 
the  excitements  and  the  causes  of  fatigue  that 
are  inherent  in  his  profession,  sometimes  from 
the  cares  and  disappointments  or  even  the 
excesses  of  all  kinds  to  which  he  was  exposed  in 
the  social  conditions  in  which  he  has  hitherto 
lived ;  in  short,  he  thus  removes  from  his  mind 
all  the  factors  of  overpressure  and  moral  dejection 
that  engendered  the  neuropathic  state  or  helped 
to  keep  it  up.  He  ceases  to  have  constantly 
before  his  eyes  the  objects  and  the  beings  that 
have  for  long  been  the  witnesses  of  his  sufferings 
and  have  been  closely  associated  with  the  memory 
and  the  thought  of  his  daily  troubles  and  miseries. 
In  withdrawing  from  his  habitual  circles,  the 
patient  further  escapes  the  often  too  attentive 


PSYCHOTHERAPY.  185 

cares  of  his  relatives  and  the  incessant  questions 
about  his  health,  or  one  symptom  or  another  of 
his  complaint,  with  which  they  overwhelm  him ; 
he  breaks  away,  so  to  speak,  from  that  moral 
atmosphere  made  up  of  solicitude  and  commisera- 
tion, and  sometimes  also  of  ironical  indifference, 
by  which  his  mental  depression  and  the  irrita- 
bility of  his  temper  have  been  fostered.  In 
breaking  abruptly  with  his  habits,  the  neurasthenic, 
if  in  his  new  abode  he  comes  under  the  cheering 
influence  of  a  suitable  climate  and  of  the  tranquil 
life  of  the  fields,  renews,  so  to  speak,  his  mental 
imagery,  and  his  hypochondriacal  ideas  tend  to  be 
obliterated.  The  discipline  of  the  treatment  pre- 
scribed to  him  restores  little  by  little  the  energy 
of  his  will.  A  new  personality  begins  to  be 
substituted  for  the  old.  If  at  this  moment  the 
physician  intervenes  and  influences  his  mind  with 
cheering  and  ably  conducted  suggestions,  the 
essential  conditions  of  the  psychical  treatment  of 
the  neurasthenic  state  will  be  realised. 

Isolation,  that  is  to  say  residence  in  a  special 
establishment,  and  separation  from  the  family, 
are  the  essential  elements  of  the  systematic 
method  of  Dr.  Weir  Mitchell,  a  method  that  we 
shall  later  set  forth  in  detail.  But  apart  from 
this,  isolation  must  sometimes  be  imposed,  either 
alone  or  associated  with  other  hygienic  measures, 
in  various  forms  of  nervous  exhaustion ;  and  we 
must  here  indicate  the  cases  in  which  it  seems  to 


186  NEURASTHENIA. 

us  to  be  absolutely  necessary.  It  is  clear  that 
thereis  a  whole  group  of  neurasthenics  who  can 
be  treated  and  cured  while  still  left  with  their 
families.  Such,  for  example,  are  those  who  have 
fallen  into  the  slight  form  of  nervous  exhaustion 
in  consequence  of  excessive  bodily  fatigues  or 
intellectual  overpressure.  On  the  other  hand, 
whatever  be  the  cause  of  the  neurasthenia,  pro- 
longed isolation  and  cessation  of  all  relations  with 
the  family  must  be  formally  prescribed  to  the 
patient  whenever  he  exhibits  one  of  the  following 
symptoms  :  profound  moral  prostration,  anorexia, 
persistent  hypochondriacal  ideas,  phobias,  crises 
of  anxiety ;  and  the  same  holds  good  when  to  the 
fundamental  troubles  of  nervous  exhaustion  are 
added  a  chronic  intoxication,  such  as  alcoholism, 
morphinism,  chloralism,  etherism,  etc.  The  moral 
decay  and  the  enfeeblement  of  the  will  that 
accompany,  or  rather  that  cause,  these  symptoms, 
constitute  the  fundamental  character  of  such 
neuropathic  conditions.  And  it  is  precisely  these 
alterations  of  the  personality  that  call  impera- 
tively for  the  isolation  of  the  patient.  Speaking 
generally,  the  physician  must  also  insist  on 
separation  every  time  that,  in  his  investigations 
into  the  invalid's  surroundings,  he  discovers  on 
the  part  of  those  living  with  him  either  exagger- 
ated tenderness  or  disobliging  indifference,  or  an 
irritating  want  of  comprehension  of  his  feelings 
of  malaise  and  his  sufferings. 


PSYCHOTHERAPY.  187 

There  is,  as  we  said,  among  the  hygienic  or 
therapeutic  measures  that  usually  constitute  the 
treatment  of  nervous  exhaustion,  a  certain  number 
of  physical  agents  the  application  of  which  may 
influence  the  mental  state  of  the  invalids  in  the 
happiest  manner.  In  the  front  rank  of  these 
therapeutic  measures  that  are  capable  of  acting 
indirectly  on  the  patient's  mind  must  be  placed 
Electricity  in  its  various  modes  of  application. 
There  is  no  doubt  that  good  results  have  some- 
times been  obtained  from  static  electricity  (baths, 
douches,  frictions,  etc.),  or  from  the  constant 
current,  or  faradisation ;  on  some  occasions  the 
general  condition  of  the  patient  has  been  sensibly 
improved,  on  others  some  conspicuous  symptom 
has  disappeared.  It  is,  however,  legitimate  to 
hold  that  the  majority  of  the  successes  that  have 
been  ascribed  to  electro-therapeutic  measures  are 
much  rather  attributable  to  the  frame  of  mind  in 
which  the  patients  submit  themselves  to  this 
kind  of  treatment,  than  to  the  organic  modifica- 
tions that  it  may  have  effected  in  their  nerve 
centres.  There  are,  in  fact,  some  subjects  who 
for  one  reason  or  another  are  convinced  in  advance 
of  the  efficacy  of  "  electrical  treatment "  ;  they 
have  faith  in  it.  Others,  of  moderate  culture,  are 
vividly  impressed  by  this  physical  agent  whose 
nature  seems  to  them  mysterious  and  powerful. 
Among  these  subjects,  who  are,  so  to  speak, 
prepared  for  a  therapeutic  miracle,  the  spark  or 


188  NEURASTHENIA. 

the  effluvium  quickly  produces  a  beneficial  auto- 
suggestion. Mobius  estimates  that  four-fifths  of 
the  successes  obtained  by  electrotherapeutics  are 
due  to  the  suggestive  action  that  the  use  of  it 
exerts  on  the  patients'  minds1.  Eulenburg  holds 
that  the  proportion  of  this  class  of  cases  is  one 
fifth  only.  It  seems  to  us  difficult  to  draw  up  in 
exact  figures  the  balance-sheet  of  the  successes 
of  electrical  treatment  that  are  attributable  to 
suggestion.  We  do  not  deny  that  electricity  may 
render  real  services  apart  from  all  moral  influ- 
ence, but  it  seems  to  us,  as  it  does  to  many  good 
observers,  that  its  psychotherapeutic  action  is  in- 
contestable. The  duty  of  the  physician  then  is 
to  discern  exactly  the  cases  in  which  the  patient 
is  capable  of  benefiting  by  this  means  of  indirect 
suggestion,  and  to  apply  it  then  with  all  the  care 
and  all  the  seriousness  required. 

The  cold  water  cure  is  another  good  stimulant 
to  the  mental  energy.  A  feeble-willed  sufferer 
from  psychical  asthenia,  who  forces  himself  to 
rise  every  day  at  a  fixed  hour  in  order  to  be 
played  upon  by  a  stream  of  cold  water,  unden- 
iably exercises  his  faculty  of  volition.  It  is  the 
same  with  the  rule  of  life  imposed  on  the  patient 
by  the  physician  ;  the  discipline  of  the  treatment 
to  which  he  is  subjected  re-awakes  and  steadily 
strengthens  the  invariably  somnolent  will.  Regu- 
larity in  the  hours  of  meals  and  of  sleep  also  acts 

i  Mobius,  Schmidts  Jahrbuch,  1889. 


PSYCHOTHERAPY.  189 

favourably  on  the  invalid's  moral  condition.  He 
ceases  to  dally  in  the  feeble  inactivity  and  the 
meditation  over  his  ills  to  which  he  is  accus- 
tomed ;  little  by  little  he  regains  confidence  in  him- 
self, and  he  begins  more  and  more  to  believe  in 
the  eventual  cure  of  his  malady. 

Here  arises  the  question  if  neurasthenics 
should  abstain  from  all  intellectual  work,  and,  if 
not,  in  what  measure  and  under  what  form  it 
should  be  permitted  to  them.  It  is  evidently  im- 
possible to  formulate  an  absolute  rule  in  this 
respect.  The  line  of  conduct  to  be  followed  in 
this  matter  naturally  varies  from  case  to  case ;  it 
depends  at  once  on  the  neurasthenic  himself,  and 
on  the  principal  cause  and  even  the  form  of  his 
neurasthenia.  Thus  prohibition  not  only  of  men- 
tal work  but  even  of  all  reading  is  indicated  in 
the  case  of  patients  who  have  fallen  into  pure 
cerebrasthenia  in  consequence  of  exaggerated  in- 
tellectual toil.  These  overdriven  subjects  grow 
quickly  better  under  the  influence  of  rest  to  the 
mind  and  of  a  sufficiently  prolonged  stay  in  the 
country,  with  the  addition  of  walks  and  some 
physical  exercises. 

On  the  other  hand,  a  patient  who  has  become 
neurasthenic  inconsequence  of  disappointments  or 
sorrows,  may  receive  benefit  from  daily  but  mod- 
erate intellectual  work.  If  he  apply  his  mind  for 
one  or  two  hours  every  day  to  a  subject  of  study 
that  has  sufficient  attraction  for  him,  he  will  find 


190  NEURASTHENIA. 

in  this  practice  an  efficacious  distraction  from  his 
sorrowful  thoughts,  and  a  means  of  breaking  the 
course  of  his  cares  and  painful  agitations. 

The  majority  of  these  invalids,  with  the  excep- 
tion always  of  those  who  are  attacked  by  the 
serious  form  of  neurasthenia,  and  who  are  con- 
sequently obliged  to  take  complete  rest  of  body 
and  mind,  should  be  permitted  to  devote  an  hour 
and  a  half  at  most  each  day  to  reading.  The 
choice  of  books  is  sometimes  very  important,  and 
certain  invalids  should  be  guided  in  their  reading. 
This  naturally  requires  on  the  part  of  the 
physician  a  thorough  knowledge  of  the  moral  con- 
dition of  his  patient,  of  his  tendencies  and  mental 
peculiarities,  his  character  and  his  habitual  pre- 
occupations. Nor  is  the  time  of  the  day  that  the 
patient  devotes  to  reading  a  matter  of  indifference ; 
excitable  neurasthenics,  and  more  especially  those 
who  suffer  from  insomnia,  should  abstain  from 
all  reading  in  the  hours  before  going  to  bed. 
During  these  same  hours  it  is  equally  important 
that  the  sufferers  avoid  long  conversations  on 
subjects  that  touch  them  closely  or  that  interest 
them  too  keenly.  All  these  small  measures  of  moral 
hygiene  dealing  with  the  intellectual  work  and 
the  hours  of  mental  rest  and  activity  imposed  on 
the  patient,  are  often  more  efficacious  than  one 
would  think,  and  the  physician  must  take  care 
not  to  neglect  them  when  he  comes  to  draw 
up  for  the  patient  the  programme  of  the  life 


PSYCHOTHERAPY.  191 

to  be  led  during  the  period   of  the   treatment. 

Independently  of  reading,  there  are  some  dis- 
tractions that  must  not  only  be  permitted  but 
even  recommended  to  certain  neurasthenics. 
Drawing,  photography,  and  music  divert  and  en- 
liven these  patients,  especially  when  they  have 
acquired  some  skill  in  the  exercise  of  these  accom- 
plishments, and  can  derive  from  them  a  sensible 
satisfaction  of  their  self-esteem.  But  in  this,  as 
in  all  things,  it  is  important  to  proceed  with  mod- 
eration, and  to  avoid  excess  and  above  all  fatigue. 

There  is  a  rule  of  mental  hygiene  whose  im- 
portance seems  to  us  very  great,  but  which,  un- 
fortunately, is  often  very  difficult  to  apply  in 
every-day  practice:  we  refer  to  the  choice  of  the 
person  or  small  number  of  persons  with  whom 
the  invalids  enter  into  daily  contact  and  with 
whom  they  have  to  converse.  It  is  not  good  for 
neurasthenics  to  live  in  solitude.  They  very  often 
seek  it  out,  and  take  pleasure  in  it,  either  because 
the  presence  of  another  person  annoys  their  in- 
tellectual idleness  and  their  apathy,  or  because  it 
interferes  with  their  day-dreamings,  their 
broodings,  and  their  hypochondriacal  preoccupa- 
tions. Consequently  they  should  often,  or  rather 
always,  be  accompanied  during  their  walks  and 
their  hours  of  rest  by  some  intelligent  and  tactful 
person,  either  sick-nurse  or  friend,  who  knows 
how  to  interest  them  and  distract  them  with  con- 
versation, but  always  without  tiring  them ;  this 


192  NEURASTHENIA. 

is  doubtless  a  very  delicate  part  to  play,  but  it  is 
in  the  highest  degree  beneficial  when  it  is  well 
carried  out.  Hence  it  is  necessary  to  prohibit 
formally  to  neurasthenics  placed  in  special  estab- 
lishments, and  so  living  in  the  immediate  neigh- 
bourhood of  other  neurasthenics,  the  contact  and 
society  of  those  like  themselves;  the  condition  is 
necessary,  but  the  practical  realisation  of  it  is,  it 
must  be  recognised,  often  very  difficult.  On  this 
point  the  physician  cannot  be  too  attentive  or 
exercise  too  much  supervision. 

2.  Psychotherapeutical  role  of  the  Phy- 
sician.— Hypnotic  Suggestion. — Suggestion  in  the 
waking  state. — Moral  guidance  and  psycho  therapy 
by  means  of  reasoning.  (Direct  psychotherapy). 

In  addition  to  the  indirect  psychotherapy  of 
which  we  have  just  spoken,  there  is  also 
direct  psychotherapy,  which  comprises  the  sum 
total  of  the  psychical  measures  which  the 
physician  may  employ  to  act  on  the  mind  of  the 
neurasthenic. 

Before  stating  its  precise  nature  and  mode 
of  employment,  it  is  necessary  to  call  attention 
to  the  fact  that  this  psychotherapy,  which, 
according  to  Grasset's  excellent  definition,1  is 
treatment  by  psychical  measures,  is  not  one 
and  single.  It  has  various  forms,  among  which 
the  medical  man  will  have  to  choose,  and 

1  J.  Grasset,  La  Psychotherapie,  in  Revue  des  Deux  Mondes,  15th 
September,  1905.  See  also  Bernbeim,  Suggestion  et  Persuasion,  in 
Revue  mid.  de  I'Est,  1905. 


PSYCHOTHERAPY.  193 

which  it  is  as  well   to  indicate  at   the   outset. 

Psychotherapeutic  measures  of  procedure 
may  practically  be  reduced  to  three :  psycho- 
therapy by  hypnotic  suggestion,  that  by  suggestion 
in  the  waking  state,  and  finally  that  by  persuasion, 
which  it  is  more  rational  to  call  psychotherapy  by 
reasoning. 

The  first  of  these  is  applied  by  means  of 
hypnotic  sleep.  We  shall  show  that  it  is  of  little 
service  in  the  treatment  of  neurasthenia,  and 
that  it  has  more  disadvantages  than  advantages. 

The  second,  suggestion  in  the  waking  state,  con- 
sists, if  one  takes  the  term  literally,  in  using  the 
authority  and  tact  that  the  physician  has  been 
able  to  acquire  in  such  a  way  as  to  impress  on 
the  patient  an  idea,  belief,  or  conviction  that  is 
opposed  to  the  morbid  idea,  belief,  or  conviction. 

As  to  the  third,  which  has  been  much  spoken 
of  lately  under  the  name  of  psychotherapy  by 
persuasion,  it  has  been  contrasted  with  the  second 
as  being  fundamentally  different.  It  consists  in 
reasoning  with  the  patient,  in  discussing  with 
him  the  causes  and  the  symptoms  of  his  complaint, 
in  showing  him  the  reason  and  the  mental  me- 
chanicism  of  his  sufferings,  and  in  making  him 
understand  in  what  ways  he  is  deceiving  himself 
and  how  he  is  acting  wrongly.  The  new  designa- 
tion that  some  authors  have  employed  to  denote 
this  very  old  form  of  psychotherapy,  seems  to  us 
bad. 

Neurasthenia.  13 


194  NEURASTHENIA. 

Persuasion,  in  fact,  is  not  a  means  but  a  result, 
or,  if  it  be  preferred,  an  aim.  All  psychical  treat- 
ment, direct  or  indirect,  and  whatever  be  the  form 
of  procedure,  aims  at  the  persuasion  of  the  patient. 
When  one  suggests  to  a  hysteric  whose  hand  is 
paralysed  the  idea  that  his  paralysis  does  not 
exist,  what  one  does  is  to  persuade  him  by  affirma- 
tion or,  if  the  expression  be  preferred,  by  sugges- 
tion ;  and  in  the  same  way,  when,  by  a  long  process 
of  reasoning,  one  demonstrates  to  a  dyspeptic  who 
believes  himself  attacked  by  cancer  that  he  is  mis- 
taken, one  again  succeeds  by  means  of  persuasion. 
The  ways  and  means  are  different  in  the  two 
cases,  but  the  end  is  the  same.  Hence  there  is 
no  psychotherapeutical  method  which  can  justly 
be  termed  psychotherapy  by  persuasion ;  and  on 
the  other  hand  every  psychotherapeutical  method 
may  be  described  as  a  mode  of  persuasion.  What 
has  improperly  been  called  psychotherapy  by  per- 
suasion is  really  psychotherapy  by  reasoning. 

Is  psychotherapy  by  reasoning  as  different  from 
psychotherapy  by  suggestion  as  has  been  said  ? 
Theoretically  perhaps  it  is;  and  to  a  certain  extent 
one  is  justified  in  saying,  with  Grasset,  that  the 
latter  appeals  to  the  lower  mental  levels,  including 
unconscious,  automatic,  involuntary  actions, 
whereas  the  former  acts  on  the  higher  mental 
levels,  to  which  belong  conscious  and  voluntary 
actions.  Hence  it  has  been  thought  that  "  if  the 
"  two  methods  have  both  a  curative  psychical 


PSYCHOTHERAPY.  195 

"  action,  yet  they  differ  from  one  another  in  that 
"  the  higher  fortifies,  and  the  lower  weakens,  the 
"  unity  and  strength  of  the  higher,  conscious  and 
"  free  personality."1  This  thesis  has  been  developed 
at  length  by  Dubois  in  his  work,  Le  Traitement 
des  Psychonevroses,  and  has  been  adopted  by 
Pagniez  &  Camus  in  theirs.  It  is  incontestable 
that  pure  suggestion,  which  involves  the  complete 
submission  of  the  patient  to  the  operator,  is  not 
calculated  to  develop  the  energy  of  the  will,  but 
tends  rather  to  weaken  it ;  and  on  the  other  hand, 
it  is  no  less  certain  that  by  reasoning,  which  is  a 
method  of  re-education,  we  may  strengthen  failing 
energy  and  bring  out  the  personality  of  the  patient. 
But  in  practice  things  do  not  go  altogether  in 
this  way ;  reasoning  and  suggestion  are  almost 
always  combined  to  a  greater  or  less  degree.  And 
if  one  can  in  strictness  imagine  a  suggestion  in 
the  waking  state  from  which  all  logical  elements 
are  wanting,  yet  there  is  no  persuasive  reasoning 
that  does  not  involve  the  intervention  of  sugges- 
tion in  some  degree.  In  every  effort  of  re-educa- 
tion made  by  the  physician,  moral  feeling  enters 
into  action  in  the  patient's  mind  as  well  as  intelli- 
gence. Bernheim  has  rightly  said :  "  Is  it  true 
"that  persuasion  appeals  solely  and  always  to  the 
"  reason,  and  that  it  is  as  persuasive  when  it 
"  appeals  simply  to  the  reason  alone  ?  The  advocate, 
"  the  business  man,  the  diplomatist,  the  earnest 

1  J.  Grasset,  loc.  cit.,  p.  35. 


196  NEURASTHENIA. 

"  preacher  and  moralist,  do  they  not  know  that, 
"  in  order  to  convince  and  make  an  impression, 
"  it  is  not  enough  to  write  or  to  deliver  their 
"  reasoning  coldly  ?  Gestures,  the  intonation 
"  of  the  voice,  the  turning  of  sentences,  the  magic 
"  of  style,  words  that  take  effect,  that  is  to  say 
"  that  make  an  impression,  all  these  unite  to 
"  drive  the  notion  into  men's  heads,  and  to  per- 
"  suade  them."1  If  this  were  not  so,  then  the 
phonograph  might  often  be  substituted  for  the 
physician  in  the  practice  of  psychotherapy.  The 
foregoing  leads  us  to  express  our  belief  that  it  is 
only  artificially  that  one  can,  in  practice,  think  of 
dissociating  suggestive  psychotherapy  and  psycho- 
therapy by  reasoning.  Consequently  we  shall 
study  them  both  in  the  same  section,  but  we  must 
state  at  once  that,  as  a  rule,  more  good  is  done  to 
neurasthenics  by  an  appeal  to  their  intelligence 
than  by  an  appeal  to  their  feelings. 

1.  Hypnotic  suggestion. — It  is  certain  that  the 
profound  disorder  of  the  nervous  centres  from 
which  spring  the  groups  of  symptoms  found  in 
neurasthenia  cannot  be  permanently  and  com- 
pletely abolished  by  some  few  applications  of 
hypnotism.  Hence  "  the  hypnotic  method,"  so 
vaunted  by  some  authors  in  the  treatment  of 
diseases  of  the  nervous  system,  and  notably  of 
neuroses,  cannot  be  reasonably  proposed  as  a 
mode  of  general  treatment  of  neurasthenic 

1  Bernheim,  loc.  cit.,  p.  6. 


PSYCHOTHERAPY.  197 

conditions.  All  medical  men  who  have  watched  the 
course  of  cases  of  neurasthenia,  and  have  observed 
the  habitual  tenacity  of  the  complaint,  will  agree 
in  recognising  this.  On  the  other  hand,  it  is  cer- 
tain that  hypnotic  suggestion  can  be  of  real  service 
when  it  is  put  into  operation  to  combat  this  or 
that  incidental  symptom  of  psychical  nature  aris- 
ing in  the  course  of  nervous  exhaustion  (obses- 
sions, phobias,  etc.).  Thus  M.  Bernheim,  M.  V. 
Elden,  M.  Forel,  and  many  others  have  obtained 
either  the  improvement  or  the  disappearance  of 
such  neurasthenic  symptoms  as  cerebral  depres- 
sion, hypochondriacal  preoccupations,  insomnia, 
etc.  But  here  it  is  necessary  to  come  to  a  clear 
understanding  as  to  the  meaning  of  the  terms 
"  hypnotic  state "  and  "  hypnotic  suggestion." 
According  to  our  experience,  pure  neurasthenics, 
that  is  those  who  have  no  taint  of  hysteria,  are  not 
hypnotisable  in  the  strict  sense  of  the  word.  The 
states  of  sleep  into  which  they  are  put  by  the  various 
procedures  employed  in  such  cases  do  not  in  any 
way  exhibit  the  essential  features  of  somnam- 
bulism— unconsciousness,  f  orgetf  ulness  on  waking, 
etc. — and  similarly  the  suggestions  given  in  these 
states  of  sleep  are  not  carried  out  with  that  per- 
fect automatism,  that  unconsciousness,  that  inde- 
pendence of  those  personal  ideas  whose  combina- 
tion constitutes  the  conscious  self,  which  are  the 
distinctive  features  and  necessary  characters 
of  suggestion  properly  so  called.  This  hypnotism 


198  NEURASTHENIA. 

and  these  suggestions  can  only  be  brought  about 
in  the  case  of  hysterics  and  hystero-neurasthenics. 
In  order  that  they  may  be  possible,  there  must  be 
a  profounder  alteration  of  the  personality  than 
exists  in  pure  neurasthenic  states,  and  this  per- 
haps is  one  of  the  most  certain  lines  of  demarca- 
tion between  the  mental  state  of  the  neurasthenic 
and  that  of  the  hysteric.  Hence  there  will  rarely 
be  a  chance  of  obtaining  true  hypnotic  sleep  in 
neurasthenic  subjects.  Besides,  there  is  some 
danger  in  accustoming  the  patients,  in  training 
them  so  to  speak,  to  induced  somnambulism  ;  we 
could  here  quote  more  than  one  case  where  such 
a  practice  has  only  aggravated  the  neurotic  con- 
dition, and  even  where  it  manifestly  determined 
the  appearance  of  mental  disorders  of  real  gravity 
(wandering  and  confusion  of  the  mind).  The 
"  sleep"  to  which  neurasthenic  subjects  are  usu- 
ally put,  and  which  corresponds  to  the  first  stages 
of  hypnosis,  according  to  M.  Bernheim's  classi- 
fication, is  very  different  from  true  artificial  som- 
nambulism. The  patients  do  not  lose  conscious- 
ness of  themselves ;  they  know  what  is  taking 
place  at  "the  seance,"  though  they  close  their 
eyes  and  are  willing  to  abstract  their  minds  and 
to  sleep.  They  sleep  awake.  Thus  when,  after 
the  "  waking,"  they  obey  the  suggestion-like  in- 
stigations given  to  them  verbally  by  the  physician, 
it  is  not  in  virtue  of  a  real  unconscious  and  invol- 
untary suggestion  that  they  act.  The  mental 


PSYCHOTHERAPY.  199 

phenomenon  produced  in  them  has  only  the 
appearance  of  suggestion ;  it  is  really  quite  differ- 
ent. The  command  given  has  been  received  by 
them  in  full  consciousness;  it  has  not  escaped 
from  the  control  of  their  personality.  And  if  they 
are  docile  subjects,  convinced  of  the  intellectual 
superiority  of  the  physician,  quite  disposed  in 
consequence  to  obey  him,  and  vividly  impressed 
by  the  word  *' hypnotism"  and  by  what  they 
know  of  the  thing,  it  is  easy  to  understand  that 
they  accept  and  carry  out  the  "  suggestion  "  that 
has  been  given  to  them.  But  this  suggestion  is, 
on  ultimate  analysis,  only  a  suggestion  received  in 
the  waking  state,  facilitated  perhaps  by  the  be- 
lief of  the  invalid  in  the  efficacy  of  this  mode  of 
treatment  and  by  the  ceremonial  associated  with 
it ;  it  is,  in  sum,  equivalent  to  the  indirect  sugges- 
tions that  may  be  produced  by  any  of  the  thera- 
peutic agents  employed  in  the  treatment  of  neuras- 
thenia, such  as  electricity,  metallic  plates,  etc. 
This  kind  of  hypnotism  presents  no  great  dangers. 
It  is  certain  that  it  has  been  able  to  render  real 
services,  to  bring  about  for  example  the  abolition 
of  some  psychical  disorder  that  has  arisen  in  the 
course  of  nervous  exhaustion.  But  the  cases  in 
which  it  is  indicated  seem  to  have  been  always 
somewhat  rare.  One  can  usually  do  without  it. 
The  results  that  it  gives  can  be  obtained 
by  a  physician  of  some  slight  ability  by 
appealing  either  to  the  intelligence,  or  to  the 


200  ,  NEURASTHENIA. 

suggestibility,  of  the  patient  in  the  waking  state.1 
2.  Suggestion  in  the  waking  state.  Moral  guid- 
ance.— Psychotherapy  by  reasoning. — The  moral  in- 
fluence that  the  physician  can  exert  on  the  patient 
is  a  leading  element  in  the  treatment  of  nervous 
exhaustion.  Its  importance  assuredly  cannot  be 
exaggerated.  By  itself  it  is  able  to  modify  pro- 
foundly the  mental  condition  of  the  patients,  to 
arouse  their  energy,  to  hinder  the  development 
or  effect  the  disappearance  of  the  hypochondria- 
cal  ideas,  the  obsessions,  and  the  fits  of  anxiety 
by  which  they  are  so  often  tormented,  and  thereby 
to  produce  a  permanent  improvement  in  their 
physical  condition;  for  very  often,  as  we  have 
seen,  it  is  from  the  moral  state  that  the  greater 
number  of  the  symptoms  of  nervous  exhaustion 
proceed. 

In  order  that  the  success  of  this  psychical 
treatment  may  be  assured,  and  that  the  cheering 
action,  by  means  of  suggestion,  of  the  physician 
on  the  patient  may  be  possible  and  efficacious,  it 
is  absolutely  necessary  that  the  physician  be  able 
to  gain  the  confidence  of  his  patient  and  assume 
an  uncontested  authority  over  him.  For  this 
purpose  he  must  at  the  very  first  interview  listen 
patiently  and  with  apparent  interest  to  the  some- 
times very  long  recital  of  the  troubles  experi- 
enced by  the  neurasthenic,  read  attentively  or 

1  M.  de  Fleury,  Traitement  rationnel  de  la  neurasthenic. — Congrcs 
pour  Vavancemtnt  des  sciences.     Besanqon,  1893. 


PSYCHOTHERAPY.  201 

keep  for  future  examination  the  "slips  of  paper" 
on  which  the  latter  has  recorded  the  list  and 
analytical  statement  of  his  sufferings,  and  finally 
make  a  methodical  and  complete  physical  exam- 
ination. It  is  advantageous  also  that,  in  the 
course  of  the  interrogatory,  or  while  the  patient 
is  giving  a  description  of  his  case,  the  physician 
should  make  suggestions  or  anticipate  him,  so  to 
speak,  in  his  statement,  by  indicating  this  or  that 
symptom  or  by  mentioning  the  precise  features  of 
this  or  that  functional  disorder.  Feeling  himself 
thoroughly  examined,  listened  to,  and  understood, 
the  patient  is  thenceforward  ready  to  regard  as 
sincere  and  correct  any  opinion  that  the  physician 
may  formulate  on  the  nature  of  his  complaint, 
and  consequently  to  accept  unreservedly  the 
treatment  prescribed  to  him.  The  physician  who 
wishes  to  secure  the  confidence  of  a  neurasthenic 
must,  then,  listen  to  him  attentively,  examine  care- 
fully all  his  organs,  and  above  all  refrain  from 
any  bantering,  from  any  ironical  reflections,  how- 
ever strange  may  be  the  complaints  or  confidences 
that  he  receives.  When  this  first  point  is  gained, 
that  is  to  say  when  he  has  acquired  the  confidence 
of  the  patient,  the  physician  will  thenceforward 
be  able  to  reassure  him  authoritatively  as  to  his 
condition  by  declaring  to  him,  not  that  he  is  not 
really  ill  or  that  he  is  only  a  "  malade  imaginaire" 
but  that  he  has  no  organic  lesion,  and  that  conse- 
quently his  illness,  though  demanding  serious  and 


202  NEURASTHENIA. 

perhaps  prolonged  treatment,  is  perfectly  cur- 
able. He  can  quote  him  examples  of  patients 
who  have  been  cured,  and,  in  short,  try  to  awake 
in  him  the  hope  and  even  the  belief  in  a  speedy 
cure.  This  is,  so  to  speak,  the  basis  of  the  moral 
treatment  of  neurasthenia. 

During  the  whole  course  of  treatment  the  phy- 
sician should,  then,  by  his  words  and  his  bearing 
endeavour  to  keep  up  in  the  patient's  mind  the 
notion  that  he  is  not  a  prey  to  a  serious  malady, 
that  his  disorders  are  purely  functional,  and  that 
with  perseverance  he  will  succeed  in  getting  rid  of 
them.  By  acting  in  this  way  he  not  only  helps  to  dis- 
pel erroneous  hypochondriacal  ideas,  but  he  raises 
the  patient's  courage  and  thus  produces  stimu- 
lating effects  that  aid  in  dispelling  the  nervous  ex- 
haustion and  its  manifestations.  Nothing  stimu- 
lates activity  like  a  comforting  thought  or  a 
pleasant  impression. 

In  order  to  obtain  this  result  it  is  evidently  in- 
dispensable to  watch  closely  over  the  patient,  so 
that  on  the  least  sign  of  discouragement  or  im- 
patience one  may  intervene  and  restore  matters 
to  order.  And  yet  it  is  advisable  that  the  phy- 
sician should  avoid  seeing  his  client  too  frequently; 
otherwise  his  authority  runs  the  risk  of  wearing 
itself  out  and  his  influence  of  crumbling  away  :  he 
should  know  how  to  put  suitably  long  intervals  be- 
tween his  visits.  It  is  good  that  the  arrival  of  the 
physician  should  be  somewhat  desired;  it  ought 


PSYCHOTHERAPY.  203 

always  to  be  a  sort  of  conspicuous  event  for  the 
neurasthenic  under  treatment,  and  one  that  makes 
an  impression  upon  him.  Hence,  again,  the  phy- 
sician should  never  yield  to  the  temptation  to 
adopt  too  familiar  a  tone  with  the  patient ;  his 
attitude  ought  not  to  be  made  up  of  commiseration 
and  good-natured  attention  only;  firmness  is  also 
necessary,  and  sometimes  even  a  little  severity. 
The  patient  needs  to  feel  that  the  doctor  has  a 
superior  judgment,  and  a  firm  will  which  directs 
him  and  which  may  be  a  solid  support  to  him  in 
the  moral  reformation  that  he  is  unable  to  carry 
out  himself.  In  this  connection  M.  Bouverethas 
very  justly  remarked  that  what  M.  Legrand  du 
Saulle  so  well  said  about  mild  insanity  is  in  all 
points  applicable  to  the  treatment  of  a  certain 
number  of  neurasthenic  states.  "  If  the  patient 
"  only  receives  common-place  consolations,  and  if 
"  he  makes  compromises  with  you  on  one  or  more 
"  points,  he  goes  away  disappointed  and  never  re- 
"  turns.  The  essential  thing  that  he  relied  on 
"  finding  in  the  physician  was  an  authority  that 
"  commanded  and  subjugated  his  will,  and  not  an 
"  argumentative  affability  that  discussed  and 
"yielded." 

These  are  very  general  indications  as  to  the 
attitude  that  the  physician  should  adopt  with 
neurasthenics.  But  it  is  evident  that  his  words, 
his  actions,  and  the  little  stratagems  that  he  must 
make  use  of,  will  vary  according  to  the  different 


204  NEURASTHENIA. 

circumstances  of  the  cases.  Every  case  needs  a 
special  method,  and  is  in  a  way  amenable  to 
special  procedures  of  verbal  suggestion.  All  who 
have  had  some  slight  practice  among  this  class  of 
patients  know  how  much,  in  spite  of  very  many 
points  of  resemblance,  they  really  differ  from  one 
another  in  their  tendencies,  their  sensitiveness, 
their  character,  their  social  level,  and  their  degree 
of  intelligence,  all  of  which  are  conditions  that 
require  from  the  physician,  if  he  is  to  conduct 
the  psychical  treatment  well,  the  most  varied 
modes  of  speaking  and  acting.  Consequently, 
before  undertaking  the  moral  treatment  of  a 
neurasthenic,  he  ought  to  make  a  minute  inquiry 
not  only  into  his  history,  his  hereditary  and  per- 
sonal antecedents,  but  also  into  the  persons  around 
him,  the  circumstances  in  which  he  was  attacked 
by  neurasthenia,  and  the  real  causes,  moral  or 
other,  of  his  nervous  exhaustion.  Similarly,  when 
his  special  object  is  to  counteract  a  fixed  idea,  a 
hypochondriacal  obsession,  he  should  contrive,  by 
persuading  the  patient  to  confide  in  him,  to  trace 
it  up  to  the  incident  and  the  morbid  derangement 
that  set  the  spark  to  it.  He  will  then  be  in  a 
position  to  show  the  invalid  the  emptiness  of  his 
fears,  by  making  him  understand  that  his  atten- 
tion is  fixed  on  a  disorder  that  is  real  but  purely 
functional  and  without  gravity,  and  that  he  has 
accustomed  himself  little  by  little  to  interpret  it 
wrongly,  to  ascribe  to  it  an  importance  that  it 


PSYCHOTHERAPY.  205 

does  not  possess,  a  significance  that  is  not  the 
true  one.  This  proceeding,  which  consists  in  re- 
tracing to  the  patient  in  a  correct  and  precise 
manner  the  stages  of  his  hypochondriacal  ideas, 
and  in  some  sort  the  genesis  of  his  obsessions,  is 
well  calculated  to  impress  him.  We  could  quote 
many  examples  of  the  cure  of  fixed  ideas  by  this 
method.  But  there  is  one  condition  necessary 
for  its  application,  namely  that  the  neurasthenic 
be  endowed  with  a  sufficiently  lively  imagination. 
When  one  has  to  deal  with  a  neurasthenic  of 
penetrating  mind,  having  to  some  extent  what 
might  be  called  the  gift  of  internal  observation, 
one  must  not  be  afraid  of  giving  him  information, 
of  enlightening  him  upon  the  subject  of  his  affec- 
tion, and  of  making  him  put  his  finger,  so  to  speak, 
on  the  starting  point  and  the  evolution  of  the  obses- 
sions, the  apprehensions,  and  the  terrors  that 
torment  him.  That,  we  believe,  is  a  good  method 
of  freeing  him  from  them.  It  is  obvious  that  a 
quite  different  line  of  conduct  must  be  followed  in 
the  case  of  subjects  less  well  endowed  intellectually. 
In  such  cases  it  is  better  to  have  resource  to  proce- 
dures of  suggestion  or  indirect  demonstration,  of 
which  we  cannot,  of  course,  draw  a  complete 
picture  here.  But  let  us  take  an  example :  here 
is  a  neurasthenic  who,  in  consequence  of  having 
felt  some  pains  and  a  certain  degree  of  weakness 
in  the  lower  limbs,  imagines  that  he  is  attacked 
by  a  serious  disease  of  the  spinal  cord,  say  by 


206  NEURASTHENIA. 

tabes  dorsalis ;  he  can  be  shown  that  he  exhibits 
none  of  the  fundamental  symptoms  of  that  affec- 
tion, that  his  sensory  powers  are  intact,  that 
shutting  his  eyes  does  not  bring  on  loss  of  equili- 
brium, that  his  knee-jerks  are  preserved,  and  that 
his  pupils  are  equal  and  react  properly.1  Claus- 
trophobia, the  fear  of  open  spaces,  in  short,  all 
the  phobias  in  their  milder  forms  are  amenable  to 
more  or  less  analogous  treatment,  into  details  of 
which,  however,  we  cannot  enter  here,  because 
the  modes  of  practical  application  are,  we  repeat, 
of  the  utmost  variety.  The  action  of  the 
physician  with  regard  to  the  moral  causes  that 
are  found  so  often  at  the  origin  of  neurasthenic 
states  is  of  the  greatest  importance ;  but  this  also 
cannot  be  given  in  precise  terms.  The  conduct 
and  the  language  that  must  be  held  in  order  to 
appease  poignant  regrets  and  profound  sorrows, 
and  to  bring  the  patient  to  live,  so  to  speak,  in 
peace  with  himself,  are  evidently  very  special 
in  each  case.  This  is  one  of  the  most  delicate 
parts  of  the  role  of  the  physician,  and  it  exacts 
from  him  much  initiative,  prudence,  and  tact, 
and  at  the  same  time  an  intimate  acquaintance 
with  the  history  and  the  personality  of  the 
patient. 

1  It  must  be  remembered,  however,  that  a  slight  loss  of  equilibrium 
on  closing  the  eyes  is  not  uncommon  in  neurasthenia,  that  the 
pupils  may  be  unequal,  and  that  the  knee-jerks  are  occasionally, 
though  rarely,  absent.  Moreover  the  statement  that  the  sensory 
powers  are  intact  is  too  absolute. — Trans. 


PSYCHOTHERAPY.  207 

In  the  case  of  patients  endowed  with  intelli- 
gence, one  may  also  with  advantage  have  recourse 
to  the  methods  of  auto-suggestion  that  have  been 
studied  and  recommended  by  Dr.  P.  Emile  Levy.1 
The  method  of  meditation  is  able  to  render  real 
services.  "  One  places  oneself,"  says  Dr.  Levy, 
"in  a  quiet  room,  away  from  disturbance,  noise 
"  and  light.  One  lies  down  in  a  comfortable 
"  position,  wearing  nothing  that  can  incommode 
"  the  body.  In  short,  one  puts  oneself  in  the 
41  same  conditions  that  help  us  to  fall  asleep  at 
"  night.  Then  we  shut  our  eyes,  and  concentrate 
"  our  minds  on  the  thought  of  sleeping.  .  .  . 
"  At  a  certain  moment  we  experience  a  feeling 
"  of  torpor  and  calm  in  our  minds  and  bodies ;  our 
"ideas  and  sensations  are  dulled,  veiled  as  it 
"  were.  .  .  .  We  then  give  ourselves  suitable 
"  suggestions.  These  affirmations  are  made  for 
"the  length  of  time  that  we  judge  necessary, 
"  sometimes  mentally,  but  often,  and  better  still, 
"  aloud  or  half-aloud,  in  order  that  our  attention 
"  may  be  more  easily  taken  possession  of.  On  occa- 
"  sion  we  may  even  enlist  the  aid  of  move- 
"  ments ;  we  may  touch  ourselves,  or  lightly  rub 
"  the  painful  part.  .  .  .  When  the  suggestion 
"  is  finished,  all  we  have  to  do  is  to  open  our  eyes." 

From  what  has  been  said  it  will  be  seen  that, 
though  psychotherapy  is  of  great  use  to  neuras- 
/ 

l  Paul  Emile  L6vy.     L'education  rationnelle  de  la  volonte.     Paris : 
Alcan,  1905. 


208  NEURASTHENIA. 

thenics,  it  cannot  be  brought  under  a  single  un- 
changing formula.  The  good  doctor  is  not  he  who 
has  a  system  of  his  own,  and  applies  it  to  all  cases 
empirically,  but  he  who  is  able  to  distinguish 
special  indications,  and  to  adapt  his  treatment  to 
the  individual  psychology  of  each  patient. 


CHAPTER  III. 
DIET. 

The  diet  of  the  neurasthenic  should  have  a 
triple  aim :  (1)  to  restore  to  the  nervous  system 
its  failing  energy;  (2)  to  adapt  itself  to 
the  needs  of  the  more  or  less  atonic  stomach ; 
(3)  to  adapt  itself  to  the  requirements  of 
the  intestine,  whether  this  be  in  a  state  of 
atony,  of  spasm,  or  of  irritation.  The  number 
of  these  indications,  which  are  often  enough 
in  contradiction  with  one  another,  throws  sub- 
stantial difficulties  in  the  way  of  establishing  a 
satisfactory  regimen.  The  cases  are  frequent  in 
which  the  general  condition  is  poor  and  would  re- 
quire an  abundance  of  rich  nourishment,  but  gastric 
dyspepsia  necessitates  the  restriction  and  the  se- 
lection of  foods.  Again,  the  diet  that  suits  gastric 
atony  is  not  always  that  best  adapted  to  intes- 
tinal atony,  which  so  often  accompanies  it.  Hence 
the  physician  is  obliged  to  manoeuvre,  so  to  speak, 
and  to  prescribe  a  regimen  in  accordance  with  the 
predominant  indications.  From  what  precedes  it 
may  be  gathered  that  there  is  not  a  diet  for  neur- 
asthenics, but  there  are  diets.  Here  as  elsewhere, 

Neurasthenia  14 


210  NEURASTHENIA. 

charlatanism  and  the  spirit  of  systematising  have 
doubtless  given  themselves  free  scope ;  there  are 
medical  men  who  have  their  diet  for  neurasthenia. 
What  we  have  said  will  suffice  to  show  how 
opposed  to  clinical  medicine  these  practices  are, 
and  how  they  are  worthy  of  the  advertisement 
sheet  of  a  newspaper  rather  than  of  serious 
medical  books.  It  is  a  tautology,  but  one  which 
it  is  not  needless  to  recall,  that,  in  order  to 
practice  medicine,  the  best  thing  is  to  be  a  medical 
man,  that  is  to  say  to  look  for  the  indications 
special  to  each  case  and  try  to  fulfil  them.  Since 
the  time  of  Hippocrates  medical  men  worthy  of 
the  name  have  acted  in  this  way,  whereas,  also 
since  the  time  of  Hippocrates,  charlatans  have 
had  their  method,  their  remedy,  their  system. 

Consequently  we  shall  not  set  forth  here  our 
diet  for  neurasthenia,  but  shall  briefly  point  out 
how  and  in  what  degree  it  is  possible  to  fulfil 
the  indications  enumerated  above. 

I. 

Diet  as  a  Reconstituent  of  the 

Nervous  Energy. 

For  the  laying  down  of  a  diet  that  is  perfectly 
rational  from  this  point  of  view,  several  conditions 
are  necessary. 

(1).  It  must  be  known  precisely  what  the 
nerve  cell  absorbs  and  what  it  gives  out  again, 
both  in  the  state  of  rest  and  in  that  of  activity  ;  in 


DIET.  211 

other  words  the  phenomena  of  its  nutrition  in  the 
static  and  dynamic  states  must  be  known. 

(2).  The  exact  changes  undergone  by  the 
different  foodstuffs  while  passing  through  the 
organism  must  be  known ;  and,  taking  these 
changes  into  consideration,  a  determination  must 
be  made  of  the  quantity  and  quality  of  those  articles 
that  have  to  be  absorbed  in  order  to  carry  on  the 
work  of  the  nervous  system. 

We  are  far  from  such  exactitude.  To  speak 
truth,  we  are  almost  totally  ignorant  of  the  data 
which  would  enable  us  to  consider  in  a  practical 
manner  the  problem  as  we  have  put  it.  Because 
the  nervous  matter  of  the  cortex  contains  phos- 
phorised  fats  (cerebrin  and  lecithin)  in  its  composi- 
tion, it  has  been  thought  that  the  administration  by 
the  mouth  of  foods  or  drugs  containing  phosphorus 
would  be  able  to  restore  his  energy  to  the  neuras- 
thenic. Empirical  observation  has  not  altogether 
invalidated  this  notion ;  but  we  have  still  to  find  a 
phosphorised  substance  which  is  undoubtedly  as- 
similated by  the  nervous  matter,  and  of  which  it 
can  be  said  with  certainty  that  it  influences  the 
nutrition  and  the  functioning  of  that  matter. 

If  medical  men  have  been  led  to  lay  down  a 
tonic  dietary  for  neurasthenics,  it  is  because  it  is 
supposed,  and  not  without  reason,  that  nervous 
asthenia  is  connected  with  general  denutrition, 
and  that  restoration  of  the  physical  health  must 
remedy  the  insufficiency  of  nervous  energy.  This 


212  NEURASTHENIA. 

view  is  supported  by  the  facts  so  well  observed 
by  Weir  Mitchell  and  confirmed  by  all  observers. 
It  must  not  be  forgotten,  however,  that  neuras- 
thenics are  far  from  being  always  anaemic  and 
emaciated  invalids ;  there  are  some  whose  external 
appearance  is,  on  the  contrary,  very  satisfactory. 
This  proves  that  if  nervous  asthenia  is  often  asso- 
ciated, either  as  effect  or  as  cause,  with  a 
certain  degree  of  organic  wasting,  it  may  on  the 
other  hand  be  quite  independent  of  it. 

There  is  more  than  this:  on  no  account  should 
one  lay  down  at  the  outset  to  all  who  show  signs 
of  neurasthenia  (persistent  headache,  rachialgia, 
lassitude,  attacks  of  vertigo,  loss  of  brain  power) 
the  tonic  treatment  that  suits  only  some  of  them. 
It  is  important  to  examine  the  patient  first  with 
great  attention,  in  order  to  make  sure  that  the 
case  is  not  one  of  those  states  of  secondary  neur- 
asthenia that  require  quite  different  treatment. 

Indeed,  neurastheniform  symptoms  may  be  due 
to  disorders,  either  of  nutrition  or  of  certain  func- 
tions, which  would  only  be  aggravated  by  the  diet 
indicated  in  the  case  of  true  neurasthenics. 

This  is  what  happens,  for  example,  in  the  case 
of  many  arthritics,  either  with  or  without  in- 
creased arterial  tension.  These  patients  suffer 
from  auto-intoxication,  and  the  hyperacidity  of  the 
organic  fluids  necessitates  a  diet  moderate  in 
amount,  and  of  which  meat  and  albuminoids  in 
general  should  form  only  a  small  proportion.  It 


DIET.  213 

was  evidently  cases  of  this  kind  that  were  studied 
by  those  physicians  (Vigouroux  &  Gautrelet)  who 
recommended  feeding  neurasthenics  on  carbo- 
hydrates rather  than  on  proteids.  This  practice  is 
certainly  legitimate  in  the  special  cases  of  which 
we  are  speaking.  If  extended  to  all  neurasthenics, 
to  the  true  neurasthenics  for  example,  it  would 
be  disastrous.  This  shows  again  the  necessity  of 
a  good  diagnosis  beforehand  in  order  to  carry  out 
good  treatment. 

What  has  just  been  said  about  neurasthenics 
from  arthritic  auto-intoxication  applies  also  to 
those  suffering  from  hepatic  neurasthenia  (Glenard, 
Lagrange)  ;  in  these  cases  the  diet  must  be 
directed  in  the  first  place  to  the  liver. 

Thus  it  is  only  when  a  careful  clinical  exam- 
ination has  shown  that  the  case  is  not  one  of 
those  secondary  neurastheniform  conditions  of 
which  we  have  just  spoken,  but  one  of  true  neur- 
asthenia, that  we  must  concern  ourselves  with 
the  restorative  powers  of  the  dietary.  We  have 
already  said  that  our  knowledge  on  this  point  is 
very  vague  and  inexact.  The  important  thing  at 
least  is  that  the  nutritive  value  shall  not  be 
inferior  in  the  case  of  these  patients  to  what  it 
is  in  the  case  of  healthy  men.  It  will  be  well  to 
recall  summarily  what  physiology  teaches  us  in 
this  matter. 

It  is  well-known  that  foods  are  divided  into  three 
categories :  nitrogenous,  fatty  and  carbohydrate 


214  NEURASTHENIA. 

(starch    and    sugar)  ;    to   these   must   be   added 
salts  and  water,  of  which  we  shall  speak  later. 

a.  Nitrogenous,  fatty  and  carbohydrate  foods. — 
The  function  of  nitrogenous  or  albuminoid  food  is 
partly  to  build  up  the  framework  of  our  tissues  ; 
fats,  carbohydrates,  and  part  of  the  albuminoids 
serve  to  produce  heat  and  energy.  A  good  diet  is 
one  which  includes  these  three  classes  of  foods  in 
the  ascertained  proportions,  and  man  is  instinc- 
tively led  to  use  such  a  mixed  diet. 

According  to  A.  Gautier,1  whose  figures  corres- 
pond with  those  given  by  other  authors,  the 
following  are  the  daily  quantities  needed  by  an 
average  adult  man  of  the  European  and  North 
American  races  in  order  to  maintain  himself  in 
good  health,  without  allowing  for  more  than  a 
minimum  quantity  of  work,  or  none  at  all : 
Proteids  -  -  4  oz. 

Fats  -  -  -    2*    „ 

Sugar  or  starch  (of  which  one  fifth 
part  may  be  replaced  by  half  its  15     „ 
weight  (H  oz.)  of  alcohol) 
In  the  case   of    a    man  who   is   engaged  in 
severe  muscular  work,  these  figures  are  notably 
increased.    There  is  then  needed,  again  following 
Gautier : 

Proteids 5£  oz. 

Fats  -       3     „ 

Carbohydrates  -  -        -    22|   „ 

1  A.  Gautier,  L' alimentation  et  les  regimes,  Paris,  1904. 


DIET.  215 

A  medium  amount  of  activity  requires  inter- 
mediate quantities  of  food.  It  is  obvious  that 
these  figures  vary  more  or  less  with  age,  height, 
sex,  and  season. 

The  three  classes  of  aliments  are  indispensable 
to  health.  Life  cannot  be  maintained  on  proteids 
exclusively,  at  least  for  long,  nor  on  fats  or  carbo- 
hydrates exclusively.  But  there  is  no  disadvantage 
in  the  substitution,  to  a  certain  extent,  of  one  class 
of  food  for  another,  for  example  of  carbohydrates 
for  fats  or  vice  versa.  Fatty  and  carbohydrate 
foods,  and  a  large  part  of  the  nitrogenous  food, 
play  the  part  of  combustibles  in  the  bodily 
economy.  Now  one  combustible  may  be  replaced 
by  another.  Hence  a  common  unit  has  been 
sought  for,  which  shall  be  applicable  to  the  three 
classes  of  foods,  and  shall  enable  us  to  arrange 
diet  scales  without  reference  to  the  share  taken 
by  each  of  the  three ;  this  common  unit  is  the 
unit  of  heat  or  calorie.  It  is  well  known  that  the 
calorie  is  the  quantity  of  heat  needed  to  raise  one 
kilogramme  of  water  one  degree  Centigrade.1 

On  the  other  hand,  Rubner's  researches  have 
established  that — 

1  oz.  of  proteid  is  equivalent  to  116  calories. 
1      „      fat          „  „  264 

1      „      carbohydrate      „  122        „ 

From  which  it  appears,  on  multiplying  the 
figures  given  above  by  these  coefficients,  that  a 

1  That  is,  to  raise  1  Ib.  of  water  4°  Fahrenheit  (nearly). — Trans. 


216  NEURASTHENIA. 

male  adult  leading  a  life  of  rest  needs  to  absorb 
an  amount  of  aliment  capable  of  furnishing  about 
2,800  calories  ;  a  man  at  work  needs  much  more, 
namely  from  3,500  to  3,800  ;  and  a  woman  at  rest 
much  less,  2,000  to  2,200. 

It  follows  from  these  data  that  a  neurasthenic 
who,  from  loss  of  appetite,  sluggishness  of  the 
stomach,  difficulty  of  digestion,  or  any  other 
cause,  ingests  an  amount  of  nutriment  equivalent 
to  less  than  2,800  calories,  or  to  less  than  4  oz.  of 
proteids,  2|  oz.  of  fat,  and  15  oz.  of  carbohydrates, 
is  being  insufficiently  fed,  and  is  likely  to  see  his 
asthenic  condition  persist  or  grow  worse  rather 
than  improve. 

In  practice,  it  is  certainly  not  necessary  to 
make  a  habit  of  dosing  the  patient's  food  in  this 
minutely  accurate  way.  It  is  important,  however, 
not  to  depend  solely  on  his  statements  as  to  the 
sufficiency  or  insufficiency  of  what  he  takes  ;  and 
one  ought  to  have  a  measure  which  may  serve  as 
a  standard,  in  order  to  gain  a  precise  notion  of 
the  quantity  ingested.  For  this  purpose  recourse 
must  be  had,  (1)  to  the  occasional  weighing  of  the 
food,  (2)  to  the  weighing  of  the  patient,  and  (3) 
to  the  analysis  of  the  urine. 

From  time  to  time  the  various  foods  taken  by 
the  patient  should  be  weighed  for  two  or  three 
successive  days,  in  order  to  arrive  at  an  average  ; 
and  the  liquids  consumed  should  be  measured,  or 
at  least  the  nutritious  liquids,  such  as  milk  and 


DIET. 


217 


chocolate.  In  this  way  it  will  be  easy  to  learn — 
very  approximately — not  only  the  total  weight  of 
food  taken,  but  also  that  of  the  albuminoid,  fatty, 
and  carbohydrate  substances  separately.  All  that 
is  needed  for  this  purpose  will  be  to  consult  tables 
that  give  the  composition  of  each  kind  of  aliment. 
We  have  drawn  one  up  here  after  the  researches 
of  Konig,  Moleschott,  Balland  &  Gautier.  It 
shows  the  composition  of  the  most  frequently 
used  articles  of  diet  in  terms  of  proteid,  fatty  and 
carbohydrate  substances. 

COMPOSITION  OF  THE    PRINCIPAL 
ARTICLES  OF  DIET. 


In  100  parts  by  weight  of 

Albumen. 

Fat. 

Carbohydrates. 

Bread  (fresh  wheaten) 

Beef  (average)            
Veal  (average  lean)   ... 
Mutton  (average)        
Pork  (average  lean)  
Ham       ...         ...         ...         .. 

7-0-9-3 

20-96 
19-86 
17-11 
20-25 
15-98 

0-85 

5-41 
7-70 
5-77 
6-81 
34-62 

46-55 

0-46 
041 

Chicken  (fat)    
Turkey  (average)        

18-49 
24.70 
15-91 

9-34 
8-50 
45-59 

1-10 

Pigeon  ...         ...         ...         ... 

22-14 

1-00 

0-76 

Hare      

23-14 

1-97 

Rabbit  

21-47 

976 

0-75 

Venison  (roe-deer)      
Partridge         
Thrush  

19-77 

25-26 
22-19 

1-92 
1-43 
1-77 

1-42 
1-39 

21-60 

12-72 

Herring  (fresh)           
Mackerel          
Shad      

14-55 
19-36 
18-76 

9-03 
8-08 
9-43 

— 

Dab        

18-71 

1-93 

Sole       

17-26 

0-81 

15-71 

4-77 

Trout     

17-52 

0-74 

Skate 

22-08 

0-45 



218  NEURASTHENIA. 

COMPOSITION  OF  THE  PRINCIPAL  ARTICLES  OF  DIET. — Continued. 


In  100  parts  by  weight  of 

Albumen. 

Fat. 

Carbohydrates. 

Eggs 

12-55 

12-11 

0-53 

(about  92 

(92  to  107 

grains  per 

grains  per 

egg) 

egg) 

Meat  broth      

0-75 

0-14 

Cow's  milk      

3-66 

3-62 

4-48 

Cream  (from  cow's  milk) 

3-76 

22-66 

4-23 

Butter  (Normandy)    

0-80 

86-40 

0-18 

Potatoes          

1-30 

0-15 

20-00 

Dried  beans     

13-80 

1-95 

52-90 

Peas      ...        ...        ...        ... 

23-15 

1-89 

52-70 

20-30 

2-40 

56-00 

Asparagus        

1-79 

0-25 

2-63 

Cauliflower      

2-48 

0-34 

4-55 

Carrots  

1-23 

0-30 

9-17 

3-49 

0-58 

4-44 

Barley  meal     ...        

11.38 

1-53 

71-22 

Oatmeal           

9.65 

3-80 

69-55 

Rice  Sour         

5-6-4 

0-8-4 

78-S3 

Cheese  (Gervais)        

14-32 

43-22 

— 

,,       (Brie)  

18-97 

25-87 

0-83 

,,      (Gruyere)       

29-49 

29-75 

1-46 

„      (Dutch)          

28-21 

27-83 

2-50 

Apples   .. 

0-36 

0-82, 

7-22 

Greengages      ..          

0-41 

0-91     „ 

8-24 

Peaches            ..          

0-75 

0-92     ? 

13-65 

Apricots 

0-49 

1-16     8 

1000 

Cherries           ..          

0-67 

0-91  ~g 

10-24 

Pears    ... 

0-36 

0-20  §; 

11-80 

Strawberries  

0-54 

0-93    " 

7-00 

Grapes  .. 

0-60 

_  t 

14-22 

But  we  must  not  lose  sight  of  the  fact  that  the 
nutritive  value  of  foods  is  not  in  exact  corres- 
pondence with  their  composition.  Not  to  mention 
the  elaboration  undergone  in  digestion,  which 
varies  with  the  healthiness  or  the  disorder  of  the 
gastric  and  intestinal  functions,  we  must  take 
into  account  the  waste  matters  that  are  not 


DIET.  219 

absorbed  but  are  rejected  in  the  stools ;  these 
vary  in  the  case  of  different  substances,  even 
when  the  stomach  and  intestine  function  normally. 
If  we  did  not  take  into  calculation  the  coefficient 
of  utilisation  of  the  different  foods,  we  should 
make  gross  errors  in  our  estimates.  In  100  parts 
by  weight  of  lentils  there  are  20'3  parts  of  pro- 
teids,  and  58'4  of  fats  and  carbohydrates  ;  hence 
one  might  infer  that  lentils  are  more  nutritious 
than  average  beef,  which  gives  on  analysis  20'96 
per  cent,  of  nitrogenous  matter  and  5*87  of  fats 
and  carbohydrates.  This  deduction  would  be 
quite  erroneous,  for  whereas  the  co-efficient  of 
utilisation  of  beef  is  97*5  per  cent.,  that  of  lentils 
is  only  60  per  cent.,  the  latter  leaving  residue 
amounting  to  40  per  cent,  in  the  stools,  while  beef 
leaves  only  2'S.1  This  shows  the  importance  of 
taking  into  account  the  coefficient  in  question. 

According  to  Riibner,  5'5  per  cent,  of  the 
organic  matters  of  an  average  mixed  diet  are  ex- 
creted in  the  stools.  Gautier,  to  whom  we  are 
indebted  for  this  information,  considers  the  figure 
too  high  ;  according  to  him,  it  should  not  be 
perceptibly  above  4 '5  to  5  if  the  diet  is  good  and 
digestion  normal.2  In  reality  such  complete  diets 
as  milk,  meat,  bread,  and  butter,  or  meat,  potatoes, 
flour,  peas,  butter,  and  cheese,  which  correspond 
nearly  to  the  customary  fare  of  workmen,  give  a 

1  This  still  leaves  a  balance  in  favour  of  lentils,  if  proteids,  fats 
and  carbohydrates  be  added  together. — Trans. 
a  A.  Gautier,  op.  cit.,  pp.  40  seqq. 


220  NEURASTHENIA. 

total  utilisation  value  varying  from  95  to  87  per 
cent. 

We  borrow  from  Gautier  the  following  table, 
which  shows  the  coefficient  of  utilisation  of  the 
commonest  articles  of  food,  in  so  far  as  their  pro- 
teid  constituents  are  concerned. 

Percentage  of 
proteids  utilised.          Residue. 

Beef  -  97'5  2'5 

Fish  -  97'3  27 

Milk  (casein)      -  -  917  8'3 

White  bread  (gluten)  -  78'9  21 '1 

Whole  meal  bread  (gluten)  587  41 '3 

Lentils  (legumin)  -  60'0  40'0 

Peas  (legumin)  -  72'2  27'8 

Haricot  beans  (legumin)  -  69'8  30'2 

Rice  (gluten)     -  -  75'0  25'0 

Potatoes  (legumin)    -  -  78'0  22'0 

Cabbage  (legumin)     -  -  81*5  18'5 

This  is  not  all.  It  must  be  remembered  that 
proteids  are  not  absorbed  in  their  natural  state, 
or  at  any  rate  without  preliminary  chemical 
modifications.  They  first  undergo  a  process  of 
dissociation,  and  are  reduced  to  more  elementary 
albumens.  Then  a  second  process  takes  place, 
this  time  of  reconstruction,  which  modifies  these 
albumens  again  and  renders  them  identical  with 
those  of  which  our  bodies  are  composed.  The 
more  the  nitrogenous  substance  resembles  those 
of  our  tissues,  the  more  easily  is  this  double 


DIET.  221 

series  of  operations  carried  out.  It  appears  cer- 
tain that  it  is  more  easy  and  complete  in  the  case 
of  the  albumen  of  meat  than  in  that  of  vegetables. 
Thus  the  chemical  composition  of  the  different 
foods  does  not  give  us  the  exact  measure  of  their 
nutritive  value. 

It  was  necessary  to  recall  these  data  as  a 
caution  against  the  error  of  believing  that  it  is 
enough  to  know  the  weight  and  composition  of 
substances  introduced  into  the  alimentary  canal, 
in  order  to  calculate  the  exact  quantity  of  those 
which  are  absorbed  and  which  serve  either  to 
build  up  the  tissues  or  to  produce  the  necessary 
calories. 

Information  derived  from  the  nutritive  value  of 
the  food  consumed  will  give  only  approximate 
indications.  It  may  usefully  be  supplemented  by 
the  results  of  weighing  the  patients.  It  is 
advantageous  to  weigh  them  from  time  to  time, 
at  fixed,  if  not  very  short,  intervals.  Thus  it  can 
be  learnt  if  they  are  putting  on  flesh,  remaining 
stationary,  or  becoming  thinner,  knowledge  which 
it  is  very  useful  to  have  when  treating  neuras- 
thenics. 

It  must  not  be  forgotten,  however,  that  increase 
in  weight  cannot  be  regarded  as  a  sufficient 
criterion  of  good  nutrition  of  the  nervous  system. 
With  an  excessive  proportion  of  fats  and  carbo- 
hydrates in  his  diet,  the  patient  will  grow  heavier; 
but  it  is  not  proved  that  in  such  conditions 


222  NEURASTHENIA 

he  will  augment  his  nervous  energy.  Thus 
we  must  regard  as  defective  those  systematic 
regimes  which  are  held  in  honour  in  certain 
establishments  out  of  France,  and  which  aim 
principally  at  fattening  the  patients. 

The  analysis  of  the  urine,  carried  out  at  con- 
siderable intervals,  also  gives  us  information  as 
to  the  nutrition  which  it  is  well  to  take  into 
account.  As  a  matter  of  fact,  these  analyses 
enlighten  us  only  about  the  salts  and  proteids 
absorbed,  as  the  fats  and  carbohydrates  give  rise 
to  products  of  oxidation  that  are  eliminated  by  the 
lungs  and  not  by  the  kidneys.  Doubts  have  been 
thrown  on  the  significance  of  the  figures  indicating 
the  absolute  amount  of  the  salts  and  the  various 
products  of  proteid  transformation  in  the  urine 
(urea,  uric  acid,  etc).  It  has  been  said  that  what 
is  important  to  know  is  not  so  much  the  quantity 
of  phosphorus,  sulphur,  and  nitrogen  eliminated, 
as  the  form  under  which  they  are  eliminated,  and 
it  has  been  proposed  to  substitute  the  method 
called  that  of  coefficients  for  the  simple  quanti- 
tative estimation  of  these  different  substances. 
Thus,  for  example,  instead  of  estimating  all  to- 
gether the  total  nitrogen  of  the  urine,  one  esti- 
mates this  total  nitrogen  on  the  one  hand,  and  on 
the  other  hand  the  nitrogen  of  the  urea.  The  ratio 
between  these  two  figures  e"£gL*SJsr==?s)» 
which  in  the  normal  state  is  about  0'85  on  an 
average,  and  which  has  been  called  the  nitrogenous 


DIET.  223 

coefficient,  is  said  to  show,  by  its  variations, 
modifications  of  the  nutrition  as  to  which  no 
exact  information  is  given  by  the  quantities  con- 
sidered separately.  Now  we  are  far  from  being 
sufficiently  informed  as  to  the  value  of  this 
coefficient,  and  of  several  others  that  have  been 
proposed.  From  our  present  point  of  view  they 
have  but  little  interest.  According  to  the  re- 
searches of  Marcel  and  Henri  Labbe1,  the  quali- 
tative and  quantitative  relations  that  exist  between 
the  composition  of  the  food  and  that  of  the  urine 
enable  us  to  affirm  that,  for  the  most  part  at 
least,  the  constituents  of  the  urine  do  not  come 
from  the  destruction  of  the  tissues,  but  from  the 
combustion  of  the  aliments  introduced  into  the 
body.  According  to  these  authors,  the  urinary 
excretion  is,  above  all,  the  expression  of  the 
mode  of  alimentation.2 

This  shows  that  the  absolute  quantities  given 
by  analysis  of  the  urine  are  able  to  give  us  more 
information  than  has  recently  been  supposed  as 
to  the  mode  of  alimentation  of  our  patients  and 
its  sufficiency  or  insufficiency,  at  least  so  far  as 
salts  and  proteids  are  concerned.  We  must 

1  Presse  medicate,  18th  July,  3rd  Dec.,  1904,  llth  Feb.,  1905. 

2  According  to  Prof.  Halliburton,  "  probably  in  a  man  excreting 
16  grammes  of  nitrogen  daily  ....  only  a  quarter  of  this  or  even 
less  represents  tissue  breakdown."     The   chief   end   product    of 
nitrogenous  food  katabolism  is  urea,  but  a  small  part  of  this  is 
derived  from  the  tissues.     The  chief  end  product  of  nitrogenous 
tissue  katabolism  is  creatinine,  others  being  uric  acid  and  the  purin 
bases ;  but  these  again  may  be  in  part  derived  directly  from  the 
food.     See  Essentials  of  Chemical  Physiology,  6th  ed.,  1907. — Trans. 


224  NEURASTHENIA. 

remember  however  that  the  residues  of  the 
various  substances  burnt  up  in  alimentation  are 
not  all  eliminated  with  equal  rapidity,  and  hence 
it  is  well  not  to  content  ourselves  with  a  single 
analysis  of  the  urine,  but  to  make  it  either  on 
three  successive  days  or  at  least  twice  with  a 
day's  interval.  We  must  observe  if  the  quantities 
of  each  constituent  found  in  these  analyses  are 
similar  to  or  different  from  the  daily  averages  in 
the  case  of  a  normal  man  on  an  ordinary  diet ; 
these  averages  are  usually  given  in  tables  of 
urinary  analysis. 

By  combining  the  information  furnished  by 
weighing  the  solid  food  and  measuring  the  liquids, 
with  that  given  by  weighing  the  patient  and  by 
analysing  his  urine,  we  will  succeed  in  gaining 
statistics  as  to  the  sufficiency  or  insufficiency  of 
his  diet,  at  least  so  far  as  we  are  justified,  in  our 
present  state  of  ignorance  about  the  conditions  of 
the  nutrition  of  the  nervous  system,  in  considering 
a  diet  which  is  usually  enough  for  the  general 
needs  for  the  organism  as  being  sufficient  for  a 
neurasthenic. 

The  insufficiency  of  certain  dietaries  recom- 
mended to  patients,  or  adopted  by  them  of  their 
own  accord,  becomes  manifest  as  soon  as  they 
are  submitted  to  the  above  criteria. 

Let  us  see,  for  example,  what  we  are  to  think 
of  an  exclusive  milk  diet  from  this  point  of 
view. 


DIET.  225 

A.  thousand  parts  of  unboiled  cow's  milk  contain 
about : — 

Water  -  861 '3 

Casein  and  albumen     -  49'0 

Fat  (butter)         -  -    40'0 

Sugar  of  milk 55'0 

Salts   -  4'0 

From  this  it  will  be  found  that  5  pints  of  milk, 
the  average  daily  quantity  allowed,  contain : — 

Albumen 4'9  oz. 

Fat  -    4*0    „ 

Carbohydrates         -         -         -         -     5*5     „ 

On  comparing  these  figures  with  those  of  the 
average  normal  diet  required  for  maintenance, 
which  we  have  given  above,  it  will  be  seen  that  5 
pints  of  milk  contain : — 

Too  much  albumen  -     4*9  oz.  instead  of    4'0 
Too  much  fat  -    4*0    „          „       „     2*5 

Too  little  carbohydrate  5'5    „         „       „  15'0 

Thus  a  milk  diet  is  defective  through  in- 
sufficiency of  carbohydrates  and  excess  of  fat.  It 
is  true  that  these  defects  may  be  remedied  to 
some  extent  by  skimming  part  of  the  milk  and 
adding  a  certain  quantity  of  cane-sugar  or  sugar 
of  milk. 

Moreover,  it  must  not  be  forgotten  that  from 
the  point  of  view  of  the  calories  produced,  an 
excess  of  fat,  if  it  is  well  digested  by  the  stomach, 

Neurasthenia.  15 


226  NEURASTHENIA. 

may  be  substituted  for  the  deficiency  in  carbo- 
hydrates. If  we  hold  this  view,  we  may  regard  5 
pints  of  milk  as  yielding  the  following  calories : 

Albumen      -        -     116  X  4*9  =     568 
Fat     -  -    264  X  4'0  =  1056 

Carbohydrates     -     122  X  5'5  =     671 

2295  calories 

This  would  be  nearly1  enough  for  a  patient  at 
rest,  even  allowing  for  the  loss  produced  by 
wastage  in  the  intestines.  But  the  equivalence 
of  the  three  kinds  of  food-constituents  is  in  some 
respects  theoretical,  and  a  diet  cannot  be  good,  if 
it  is  prolonged,  unless  it  has  these  in  the  relative 
proportions  required  by  a  normal  maintenance- 
diet.  Hence  a  milk  diet  would  be  insufficient  for 
a  neurasthenic  at  rest,  if  it  were  maintained  for  a 
length  of  time ;  and  much  more  would  it  be  in- 
sufficient for  a  neurasthenic  at  work.  In  the 
latter  case,  the  quantity  of  food  ought  to  be  in- 
creased, and  then  there  would  be  an  excess  of 
proteids  as  well  as  of  fat. 

As  another  example  of  an  insufficient  and  im- 
perfect diet,  we  shall  take  one  of  those  that  are 
in  fairly  frequent  use  among  the  richer  classes. 

It  may  consist,  for  example,  of  the  following 
(Diet  B) : 

1  I  have  added  the  word  nearly.  In  the  original,  the  amount  of 
the  usual  milk  diet  is  given  as  3  litres,  yielding  2428  calories  ;  and 
this,  it  is  stated,  would  be  enough  for  a  patient  at  rest. — Trans. 


DIET. 


227 


Albumen. 

Breakfast:  10  oz.  milk   - 

0'5 

Lunch  : 

2  eggs 

0-4 

4  oz.  meat 

07 

4  „     peas 

0'8 

1  „    cheese 

0'3 

Dinner  ; 

:     equivalent     to 

lunch 

i  giving 

2'2 

Add  10 

oz.  bread     - 

07 

Fat, 

0-4 
0'5 
0*2 
O'l 
0'3 

1-1 

O'l 


Carbo- 
hydrates. 

0'5 


2'4 


2'4 
5'5 


5'6 


27       10'8 


This  constitutes  a  diet  too  rich  in  albuminoids 
and  too  poor  in  carbohydrates. 

The  graphic  method  enables  us  to  see  the 
defects  of  a  diet  at  a  glance.  It  was  devised  by 
Alfred  Martinet,1  who  has  made  a  happy  use  of  it 
to  represent  the  proportion  of  nutritive  princi- 
ples in  different  articles  of  food.  The  diagrams 
that  we  propose  to  use  are  a  modification  of  those 
of  Martinet. 


6 
4 
2 

° 

1 

P 

/ 

^-^ 

. 

"--«, 

1 

FJ 

/ 

—  ^ 

•*^. 

"--*. 

C 

>      4      2      024      &    4     10     t2    14    Jt 
FIG.  4. 

Diagram   I.  (Fig.  4)    represents  the  normal 
diet  of  a  man  at  rest.     On  the  ordinate,  at  P,  is 

1  A.  Martinet,  Les  aliments  usuels,  Masson,  Paris,  1906. 


228 


NEURASTHENIA. 


marked  the  quantity  of  proteids  taken  in  24  hours  ; 
on  the  abscissa,  to  the  left  of  O,  F  shows  the 
amount  of  fat ;  and  to  the  right,  C  represents  the 
carbohydrates.  [Quantities  are  given  in  ounces] . 


p. 

-—-  . 

1  —  .. 

/ 

^—  •— 

—  -* 

~-~». 



w 

-  —  . 

-—  -. 

—  —  . 

1  —  ^_ 

C 

542      0      2      4      6      8      IO    12     14     16     18     20    22     24 

FIG.  5. 

Diagram  II.  (Fig.  5)  indicates  the  diet  of  a 
man  at  work. 


/ 

«v 

77 

p~^ 

:^- 

—  

•"•—-   , 

F' 

i 

N 

"^* 

. 

'  

C 

6     4     '2      0      2      4      6      8      10     12     14     It 

FIG.  6. 

In  diagram  III.  (Fig.  6)  the  unbroken  line 
shows  the  normal  diet  of  a  man  at  rest,  while  the 
dotted  line  represents  the  ingesta  of  a  person 
taking  5  pints  of  milk  daily.  The  diagram  shows 
at  a  glance  the  excess  of  proteids  and  fats  in  the 
latter  case,  and  the  deficiency  of  carbohydrates. 


DIET. 


229 


Diagram    IV.    (Fig.   7)     represents    diet    B 
(p.  227),  again   contrasted  with   a   normal   diet. 


We  think  that  this  method  of  representation, 
which  appeals  to  the  eye,  may  be  of  use.  It 
will  always  be  easy  to  construct  the  diagram  of  a 
neurasthenic's  diet,  if  the  weighings  that  we  have 
recommended  be  carried  out  from  time  to  time; 
and,  by  comparing  this  diagram  with  that  of  an 
average  normal  diet,  it  will  be  seen  if  the  diet  in 
question  is  satisfactory  or  defective. 

b.  The  salts  of  food.  We  eliminate  every  day, 
by  the  urine,  the  sweat,  or  the  faeces,  an  average 
of  400  grains  of  mineral  matter,  about  half  of 
which  consists  of  chloride  of  sodium,  and  the 
remainder  chiefly  of  phosphate  and  sulphate  of 
potassium,  and,  in  smaller  proportions,  of  phos- 
phate and  sulphate  of  sodium,  of  lime  and  of 
magnesia.  To  these  salts  must  be  added  some 
tenths  of  a  grain  of  iron  and  silicon,  and  some 
thousandths,  or  ten-thousandths,  of  a  grain  of 
arsenic,  copper,  manganese,  iodine,  bromine,  and 
boron.  These  last  elements  are  eliminated 


230  NEURASTHENIA. 

principally  by  the  desquamation  of  the  epithelium 
or  by  the  shedding  of  the  hair  (A.  Gautier). 

These  mineral  elements  form  an  integral  part 
of  our  organs  and  fluids,  and  must  be  present  in 
our  diet ;  animals  from  whose  food  they  are 
excluded  become  etiolated  and  finally  die,  as  has 
been  shown  by  the  experiments,  now  already  old, 
of  Chossat  and  Boussingault,  or  by  the  more 
recent  experiments  of  Forster  and  Kemmerich. 

They  are,  moreover,  very  unequally  distributed 
among  the  different  tissues.  Fresh  nerve  tissue, 
which  is  the  one  we  are  most  concerned  with, 
contains,  according  to  Gautier,  the  following 
mineral  constituents  in  10,000  parts  : 

Chlorine     -  -  4 

Phosphoric  Acid  -  8'5  — 14 

Sulphuric  Acid  -  -1*4 

Potassium  -  7'1  — 21'2 

Sodium  -  7*5  — 13 

Lime-  -  -  0'3 

Magnesia  -  -  0'65 —  7'5 

Peroxide  of  Iron         -  -  0'4  —  1'2 

Carbonic  Acid    -  -  2'1  —  3'3 

But  it  is  less  important  to  know  the  proportion 
of  mineral  substances  in  the  different  tissues, 
than  to  know  the  amount  of  these  substances 
eliminated  daily ;  for  it  is  the  latter  that  shows  us 
the  quantity  that  must  be  brought  into  the  system 
every  day  by  the  food. 


DIET.  231 

Now  in   twenty-four  hours  the   normal  indi- 
vidual eliminates : — 

Potassium  -        -  -        -  -  50  grains 

Sodium                 -  -  -  119  „ 

Lime  -  -  -  23  „ 

Magnesia 9  „ 

Peroxide  of  Iron  -  0'6  „ 

Phosphoric  Acid  -        -  -  60  „ 

Sulphuric  Acid    -  -        -  -  31  „ 

Chlorine      -  -  131  „ 

It  is  not  possible  to  state,  even  with  approxi- 
mate precision,  how  much  of  this  loss  comes  from 
destruction  of  nerve  tissue.  But  the  various  dietaries 
to  which  neurasthenics  may  be  submitted  (milk 
diet,  milk-and-vegetable  diet,  meat  diet)  contain, 
if  we  reckon  the  chloride  of  sodium  added  to 
them,  a  sufficiency  of  mineral  constituents  to 
render  it  unnecessary  to  take  the  trouble  of 
estimating  the  exact  amounts. 

Nevertheless,  the  richness  in  phosphorus  of  the 
nervous  tissue,  which  contains  not  less  than  185 
grains  altogether,  together  with  the  increased 
loss  of  phosphoric  acid  or  phosphates  that  some 
authors  have  found  to  occur  under  the  influence 
of  intense  brain  work  (Byasson,  A.  Gautier),  or 
in  nervous  conditions  (Mairet,  A.  Robin),  have 
led  medical  men  to  concern  themselves  with  the 
amount  of  phosphorus  in  the  diet  of  neurasthenics, 
and  to  introduce  phosphates  of  various  kinds  into 


232  NEURASTHENIA. 

the  treatment   of    states  of    nervous    asthenia. 

Phosphorised  substances  are  supplied  to  our 
economy  either  by  animal  foods,  or  by  vegetable 
foods,  or  in  a  simple  form  as  drugs. 

Among  articles  of  diet  of  animal  origin,  milk 
contains  a  notable  quantity  (one  part  of  phosphoric 
acid  in  2,000) ;  eggs  contain  it  in  the  form  of 
lecithin  (2  grains  of  phosphoric  acid  per  egg). 
The  compounds  of  phosphorus  in  eggs  and  milk 
are  certainly  very  easily  assimilated. 

As  to  a  meat  diet,  it  is  rich  in  nitrogen, 
but  on  the  other  hand,  as  Joulie  has  remarked, 
it  is  deficient  in  phosphoric  acid.  The  case  is  differ- 
ent with  vegetarian  diets,  which  are  poorer  in 
nitrogen  but  richer  in  phosphoric  acid.  Thus  it 
is  to  vegetables  that  we  must  turn  for  most  of 
the  phosphorus  that  we  need,  both  in  health  and 
in  disease.  Cereals  are  a  valuable  storehouse  of 
phosphorised  products;  they  may  be  used  in  the 
form  of  bread,  of  flour  boiled  into  a  pap  with  milk, 
or  in  decoctions  (Springer).1 

Experiments  that  are  already  old  have  shown 
that  if  mineral  phosphates  in  a  simple  form  are 
administered  to  a  milch-cow,  the  richness  of  her 
milk  in  phosphates  remains  unaltered ;  to  increase 
this  it  is  necessary  to  mingle  these  salts  with  the 
soil,  so  that  the  animal  absorbs  them  by  the  in- 
termediary of  grass.  As  Boussingault  has  said, 
"  phosphates,  in  order  to  be  assimilated  by  the 

i  Or  as  milk-puddings. — Trans. 


DIET.  233 

"  organism,  must  be  elaborated  in  a  special 
"  crucible,  namely  in  some  plant."1  These  facts 
lead  us  to  doubt  the  efficacy  of  those  phosphorised 
preparations  of  mineral  origin,  the  pharmaceutical 
formulas  of  which  have  been  multiplied  during 
these  last  years.  To  remedy  their  insufficiency  an 
attempt  has  been  made  (by  Gilbert  and  Posternak) 
to  isolate  from  cereals  an  organic  phosphoric  acid 
(phytin),  which  has  been  thought  to  possess  the 
properties  of  the  natural  phosphates  of  vege- 
tables. 

Whatever  be  of  the  value  of  these  different 
pharmaceutial  products,  as  to  which  clinical 
observation  has  not  yet  shown  us  anything 
decisive,  it  is  from  foods  (cereals  and  legumes) 
that  it  is  better  to  obtain,  when  one  can,  the 
phosphorised  substances  that  are  necessary  to 
the  nervous  system  of  neurasthenics. 

Some  years  ago  Joulie  recommended  the  use  of 
simple  phosphoric  acid  in  nervous  asthenia. 
Proceeding  from  the  notion  that  the  urine  of 
neurasthenics  is  generally  deficient  in  acidity,  he 
had  inferred  that  it  is  advisable  to  supplement 
the  lack  of  organic  acidity  in  these  patients  by 
the  administration  of  an  acid  medicine;  and  it 
was  as  an  agent  capable  of  increasing  the  acidity 
of  the  fluids,  rather  than  as  a  compound  of 
phosphorus,  that  phosphoric  acid  seemed  to  him 
the  best  drug  in  neurasthenia. 

1  See  A.  Martinet,  op.  cit.,  p.  20. 


234  NEURASTHENIA. 

Joulie  estimates  the  urinary  acidity  by  a  method 
devised  by  himself,  and  now  employed  in  most 
chemical  laboratories,  and  prescribes  the  drug  in 
larger  or  smaller  doses  according  as  the  deficiency 
in  acidity  is  more  or  less  marked. 

It  may  be  administered  in  the  following 
ways : — 

1.  Crystalline  Phosphate  of  Soda        -     1  oz. 
Dilute  Phosphoric  Acid  (B.P.)         -     2  „ 
Water  to         -  -    8  „ 

One  to  three  teaspoonfuls  at  lunch  and 
dinner. 

2.  Dilute     Phosphoric    Acid 

(B.P.)  -  -    2Joz. 

Tincture  of  Lemon  Peel   -     5    fluid  drachms 
Simple  Syrup  to       -        -  16    oz. 

One  to  three  tablepoonfuls  in  the  course  of  the 
day. 

In  the  hands  of  medical  men,  this  acid  medica- 
tion has  not  given  the  good  results  foretold  by 
Joulie,  and  if  some  (as  Cautru  and  Martinet)  have 
had  reason  to  praise  it,  others  have  found  it  in- 
effectual. 

We  think  that  it  should  be  reserved  for  certain 
special  cases,  but  it  is  difficult  to  determine 
which  are  these  cases,  except  by  feeling  one's 
way ;  for  the  criterion  proposed  by  Joulie,  which 
is  based  on  the  analysis  of  the  urine  and  the 
degree  of  its  acidity,  seems  to  us  to  be  insufficient. 


DIET.  235 

c.  It  has  been  thought  that  neurasthenics 
might  with  advantage  make  use  of  certain 
aliments  such  as  coffee,  tea,  kola,  or  even 
alcohol,  which  have  been  considered  as  furnishing 
energy  (Gautier).  These  are  stimulants  which, 
if  used  habitually  and  in  quantities,  bring  on  de- 
pression subsequently  to  the  stimulation.  They 
should  be  allowed  only  occasionally  and  in  small 
doses. 

II. 

The  diet  required  in  gastric  disorders. 

In  some  neurasthenics  the  digestive  functions 
are  carried  on  with  perfect  regularity.  These 
invalids  have  a  good  appetite,  and  their  gastric 
digestion  is  unimpeded;  their  general  condition 
remains  satisfactory ;  they  do  not  lose  flesh  ;  and 
if  questioned  about  the  digestive  disorders  that 
they  may  justifiably  be  supposed  to  have,  they 
reply  positively  that  they  have  no  derangement 
of  the  stomach,  and  that  they  digest  without 
difficulty.  Such  patients  are  certainly  rare,  but 
they  undeniably  exist.  In  these  cases  the  best 
plan  is  to  let  the  invalid  follow  the  diet  to  which 
he  is  accustomed,  having  first  made  sure,  how- 
ever, that  the  sensations  of  fatigue  and  prostra- 
tion habitual  to  neurasthenics  have  not  led  him 
to  increase  out  of  measure  his  quantum  of 
fermented  liquors  (wine,  beer,  etc.)  or  to  make 
an  immoderate  use  of  spirits  and  such  excitants 


236  NEURASTHENIA. 

as  tea  and  coffee.  With  this  reservation,  we 
believe  that  there  is  no  advantage  in  trying  to 
regulate  the  diet  of  these  patients  with  a  view  to 
prevent  the  contingent  appearance  of  dyspepsia. 
By  acting  in  such  a  way  one  would  run  the  risk 
of  drawing  the  attention  of  the  neurasthenic  too 
strongly  to  his  digestive  functions,  and  of  fur- 
nishing him  gratuitously  with  a  pretext  for  a  new 
hypochondriacal  idea.  Besides,  patients  of  this 
class  usually  support  a  change  of  regimen  very 
badly,  however  perfect  and  rational  it  may  be,  at 
least  in  theory. 

It  is  different  with  those  subjects,  and  they 
are  many,  who  exhibit  the  troubles  characteristic 
of  the  slight  form  of  gastro-intestinal  atony.  These 
are  patients  who  after  every  meal  experience  the 
whole  series  of  discomf  orts  that  marks  nervo-motor 
dyspepsia  :  a  feeling  of  weight  at  the  epigastrium, 
distension,  rushes  of  heat  to  the  face,  heaviness 
of  the  head,  sleepiness,  etc.  These  symptoms 
persist  as  long  as  the  work  of  digestion  continues, 
and  vanish  the  moment  that  it  comes  to  an  end. 
In  such  cases  one  has  to  do  with  simple  gastric 
atony;  permanent  dilatation  of  the  stomach  is 
absent,  and  there  is  no  gastric  stasis ;  the  food  is 
expelled  from  the  stomach  in  the  normal  period 
of  time.  Finally,  chemical  analysis  of  the  gastric 
juice  shows  that  the  secretion  has  not  undergone 
any  important  qualitative  modification  ;  in  some 
cases  there  is  found  a  slight  increase  in  the 


DIET.  237 

amount  of  the  hydrochloric  acid,  but  nothing 
more. 

What  rules  are  to  be  formulated  in  such  cases 
for  the  diet  of  the  invalid  ? 

Certain  authors  think  that  there  is  no  occasion 
for  subjecting  these  neurasthenics  to  a  special 
regimen,  and  that  general  treatment  of  the 
neurasthenia  is  enough  to  bring  about  the  cessa- 
tion of  the  dyspeptic  troubles.  This  is  sometimes 
true.  There  are  certainly  some  slight  forms  of 
nervous  exhaustion  that  improve  rapidly  under 
the  influence  of  early  and  well  managed  treat- 
ment, in  which  rest  and  hydrotherapy  form  the 
essential  part.  One  then  sees  the  dyspeptic 
syndrome  disappear  along  with  all  the  other 
functional  troubles,  and  one  has  the  right  to 
affirm,  having  put  the  matter  to  the  proof,  that 
local  treatment  was  not  necessary  to  cure  the 
disorder  of  the  digestive  functions.  But  things 
do  not  always  happen  in  this  way;  far  from  it. 
The  neurasthenic  condition  often  persists  in  spite 
of  the  general  treatment  prescribed;  the  dyspeptic 
troubles,  slight  at  the  onset,  become  more  and 
more  marked,  and  finally  the  patient  passes  from 
the  slight  to  the  severe  form  of  gastro-intestinal 
atony  ;  dilatation  of  the  stomach  and  the  pheno- 
mena of  gastric  stasis  make  their  appearance, 
and  sometimes  interfere  seriously  with  the 
patient's  nutrition.  It  may  further  happen  that 
the  patient,  although  still  exhibiting  only  the 


238  NEURASTHENIA. 

slight  form  of  atonic  dyspepsia,  may  be  so  worn 
out  by  the  persistence  of  the  discomforts  that 
overwhelm  him  at  every  period  of  digestion  that 
he  systematically  limits  the  quantity  of  food  he 
takes.  There  are  even  some  who  end  by  sup- 
pressing meals  and  substituting  for  them  tiny 
quantities  of  soup  or  milk,  so  much  do  they  fear 
the  return  of  the  dyspeptic  attack.  It  is  easy  to 
understand  that  in  such  a  case  the  patient,  being 
insufficiently  nourished,  is  not  long  in  becoming 
anaemic  and  thin,  and  in  growing  steadily  weaker. 

There  are,  further,  some  neurasthenics  on 
whom  the  tenacity  of  their  dyspeptic  disorders 
produces  an  unfortunate  impression.  They 
imagine  themselves  attacked  by  some  grave  gastric 
lesion,  by  cancer  for  example ;  being  ceaselessly 
preoccupied  with  the  condition  of  their  stomachs, 
they  grow  gloomy  and  discouraged,  and  their 
neurasthenia  is  correspondingly  aggravated. 

Thus  then  nervo-motor  dyspepsia,  even  in  its 
slightest  form,  is  not  merely  one  negligible  and 
commonplace  symptom  among  so  many  other 
manifestations  of  nervous  asthenia,  since  it  may 
set  the  spark  to  a  graver  gastric  disorder,  and 
may  seriously  impair  the  general  nutrition  of  the 
patient,  either  by  leading  him  to  lessen  his  food 
below  the  normal  amount,  or  by  throwing  him 
into  a  state  of  profound  moral  depression.  Hence 
it  is  necessary,  while  continuing  to  treat  the 
general  asthenia,  to  endeavour  also  to  mitigate 


DIET.  239 

the  digestive  disorders  due  to  gastro-intestinal 
atony.  This  will  be  effected,  not  by  prescribing 
digestive  wines  and  powders,  as  is  too  often  done, 
but  by  laying  down  a  dietary  appropriate  to  the 
patient's  condition. 

The  alimentation  of  those  neurasthenics  with 
whom  we  are  now  dealing  should  be  regulated 
with  a  view  to  preventing  the  development  of 
digestive  disorders,  and  insuring  for  the  patient 
sufficient  reparatory  material  to  aid  in  the  restora- 
tion of  his  nerve  strength.  The  quantity  of  food 
must  be  kept  at  the  normal  level,  or  even  a  little 
above.  Now  we  know  that  many  neurasthenics 
whose  stomachs  are  still  quite  able  to  digest  (we 
are  not  speaking  of  those  who  fall  into  absolute 
anaemia  and  to  whom  Weir  Mitchell's  systematic 
treatment  should  be  applied), accustom  themselves 
to  eat  little.  They  ought  to  be  carefully  ques- 
tioned on  this  point,  and  it  ought  to  be  ascertained 
with  exactitude  if  the  quantity  of  food  taken  each 
day  is  sufficient  or  not.  In  the  latter  case  the 
daily  amount  of  food  ingested  must  be  increased, 
not  abruptly  but  slowly  and  progressively.  Three 
meals  should  be  advised,  of  which  the  principal 
should  be  taken  at  mid- day.  Breakfast  should  be 
pretty  substantial;  it  is  generally  too  frugal, 
many  neurasthenics  contenting  themselves  with 
taking  a  cup  of  milk,  tea,  or  coffee,  sometimes 
without  bread.  This  meal,  though  too  small,  is 
enough  to  revive  them  a  little  and  to  dispel, 


240  NEURASTHENIA. 

though  for  a  very  short  time,  the  sensation  of 
fatigue  or  of  depression  that  they  experience  on 
waking.  Towards  ten  or  eleven  o'clock,  however, 
the  lassitude  and  prostration  reappear,  and  last 
till  lunch  time.  It  is  better  that  breakfast  should 
be  composed  of  half  a  pint  of  pure  milk,  or  of 
milk  with  the  addition  of  tea,  coffee,  or  cocoa, 
according  to  the  patient's  taste,  of  a  fresh  and 
very  slightly  cooked  egg,  and  of  a  little  toast 
thinly  spread  with  very  fresh  butter.  After  this 
light  meal  tlie  patients  generally  pass  the  time 
till  lunch  without  too  much  discomfort. 

The  diet  must  be  mixed ;  this  alone  fulfils  the 
conditions  of  good  nutrition.  Partial  and  exclu- 
sive dietaries  are  all  injurious ;  they  are  only 
applicable  in  a  small  number 'of  very  special  cases 
which  we  shall  point  out  later.  The  general  rule 
is  to  advise  neurasthenics  affected  with  simple 
atonic  dyspepsia  to  take  foods  that  are  easy  of 
digestion  and  that  contain  the  maximum  of 
nutritive  material  in  the  minimum  of  volume. 
The  disorders  that  accompany  digestion  will  thus 
be  notably  lessened,  and  the  danger  of  a  too  pro- 
longed stagnation  of  remnants  of  food  in  the 
gastric  cavity,  and  of  the  fermentations  that  may 
result  therefrom,  will  be  avoided.  The  kinds  of 
food  recommended  to  neurasthenics  should  be 
sufficient  in  number  to  enable  the  patients  to  vary 
frequently  their  bills  of  fare,  and  thus  to  avoid 
the  distaste  that  is  provoked  by  exclusive  diets  : 


DIET.  241 

they  are — beef  and  mutton  deprived  of  the  fat 
and  the  fibrous  parts,  poultry,  lean  fish  well 
cooked,  fresh  eggs  slightly  cooked.  Milk  must 
be  taken  in  moderate  quantity  and  must  be 
reserved  for  breakfast. 

Leguminous  vegetables,  such  as  French  beans 
and  peas,  and  also  spinach,  asparagus  and  all 
those  green  vegetables  that  are  poor  in  cellulose 
and  vegetable  fibre,  should  be  recommended. 
Their  nutritive  value  is  much  superior  to  that  of 
other  vegetables ;  for  they  contain  22  to  24  per 
cent,  of  albuminoid  substances,  and  a  fairly  high 
proportion  of  carbohydrates.  Their  only  disad- 
vantage is  the  great  quantity  of  water  that  they 
contain.1  Hence  it  is  indispensable  to  cook  them 
well  and  then  to  drive  off  the  water  by  heat  as 
much  as  possible  before  serving  them.  For  the 
same  reason  preserved  vegetables  are  sometimes 
better  borne  than  fresh  vegetables  and  should  be 
preferred  to  them.  Uncooked  vegetables,  let- 
tuces, cucumbers,  radishes  and  mushrooms  are  to 
be  prohibited.  Among  the  cereals  and  farinaceous 
vegetables,  rice,  sago,  mashed  potatoes  cooked 
with  milk,  and  puree  of  lentils  are  well  borne. 

Bread  must  be  used  very  moderately  and  must 
be  old  and  well  toasted. 


l  Peas  and  beans  contain  22  to  24  per  cent,  of  nitrogenous  matter, 
and  only  13  or  14  per  cent,  of  water ;  spinach  and  asparagus  con- 
tain more  than  90  per  cent,  of  water  and  only  2  or  3  per  cent,  of 
nitrogenous  substances,  the  figures  given  in  the  text  indicating  the 
proportion  of  albuminoids  in  the  solid  constituents. — Trans. 

Neurasthenia  16 


242  NEURASTHENIA. 

Stone-fruits  are  the  only  fruits  to  be  prohibited ; 
the  others  may  be  allowed  on  condition  that  they 
be  quite  ripe.  It  is  better  however  to  give  apples 
and  pears  stewed  and  broken  up. 

The  more  usual  condiments,  salt,  pepper,  and 
mustard,  are  to  be  permitted  in  moderate  quanti- 
ties because  they  excite  gently  the  patient's 
appetites,  which  are  usually  unsatisfactory. 

A  moderate  amount  of  liquid  is  to  be  drunk  at 
meals,  in  the  form  either  of  light  beer,  or  of  white 
or  red  wine  largely  diluted  with  water.  Among 
mineral  waters,  those  are  to  be  avoided  that  are 
rich  in  bicarbonate  of  soda,  and  use  is  only  to  be 
made,  in  default  of  pure  ordinary  water,  of  those 
that  are  indifferent  or  feebly  mineralised.  Though 
excessive  restriction  should  not  be  put  on  the 
quantity  drunk,  it  is  important  that  neurasthenics 
do  not  take  too  much  liquid  with  their  meals,  for 
this  would  dilute  the  gastric  juice  and  render 
digestion  in  the  stomach  slower  and  more  diffi- 
cult. To  avoid  the  bad  results  of  an  excessive 
amount  of  liquid  ingested,  patients  who  feel  a 
need  of  drinking  abundantly  at  the  end  of  meals 
should  be  recommended  to  take  juicy  fruits ; 
enemata  also  may  be  prescribed  for  the  same 
purpose.  The  kinds  of  fluid  taken  must  also  be 
closely  supervised,  because  many  patients,  in 
order  to  revive  their  always  failing  energy, 
accustom  themselves  little  by  little  to  absorb 
various  alcoholic  drinks  either  at  meals  or  during 


DIET.  243 

the  intervals,  and  so  end  in  chronic  alcoholism. 
This  same  instinctive  need  to  stimulate  the 
nervous  system  frequently  pushes  neurasthenics 
to  use  and  even  to  abuse  a  variety  of  excitants, 
such  as  tea,  coffee,  liqueurs,  tobacco.  We  believe 
that  these  different  stimulants  should  not  be 
absolutely  prohibited  except  where  there  are 
special  centra-indications.  Tea  and  especially 
coffee  should  not  be  taken  after  the  evening  meal. 
But  there  is  no  disadvantage  in  permitting  a 
moderate  use  of  them  after  the  mid-day  meal ;  it 
is  not  good  to  deprive  the  invalids  of  everything 
that  is  pleasant  to  them.  On  the  other  hand,  if 
the  patient  complain  of  symptoms  of  cerebral  or 
cardiac  excitement,  if  he  suffer  from  insomnia  or 
from  palpitations,  he  must  be  strictly  forbidden 
to  use  tea,  coffee,  or  tobacco. 

Such  should  be  the  dietary  of  neurasthenics 
affected  with  gastro-intestinal  atony  in  the  first 
degree.  It  consists,  as  we  have  seen,  of  a  mixed 
regimen  which  closely  resembles  the  normal, 
since  albuminoid,  fatty,  and  carbohydrate  aliments 
all  take  part  in  it  and  are  combined  in  the  desirable 
proportions.  Its  only  characteristic  feature  is 
the  selection,  in  each  of  the  three  classes  of  foods, 
of  substances  particularly  easy  to  digest.  It 
insures  at  once  the  general  nutrition  of  the  invalid 
and  the  regular  action  of  the  digestive  canal,  and 
must  undoubtedly  be  preferred  to  all  systematic 
and  exclusive  dietaries  which  are  supposed  to 


244  NEURASTHENIA. 

restore  the  strength  by  improving  the  nutrition 
of  the  nervous  tissue  in  particular.  Thus  Ameri- 
can authors,  especially  Beard  and  Weir  Mitchell, 
strongly  recommend  to  neurasthenics  the  use  of 
fats,  of  butter,  cream,  cod-liver  oil,  etc.  Fat  is 
certainly  a  food  necessary  to  nutrition  ;  but  it  is 
by  no  means  proved  that  an  abundant  consump- 
tion of  this  substance  exerts  a  specially  beneficial 
action  on  the  nutrition  of  the  nervous  centres. 
Moreover  fatty  substances  when  taken  in  large 
quantities  rapidly  provoke  satiety  and  are  often 
badly  borne  by  the  patients. 

An  exclusively  animal  diet  is  also  fairly  often 
prescribed  to  anaemic  neurasthenics.  They  are 
stuffed  with  roasted  and  grilled  meat  in  the  hope 
of  strengthening  them  as  quickly  as  possible. 
This  practice  is  detestable ;  clinical  experience 
and  physiological  experiment  have  proved  that 
such  a  regimen  is  incapable  of  insuring  the 
general  nutrition  of  the  organism,  that  it  encum- 
bers the  blood  and  lymph  with  extractive  sub- 
stances that  are  more  or  less  toxic,  and  it  is 
manifest  that,  where  neurasthenics  suffering  from 
gastric  atony  are  concerned,  it  is  most  unsuited 
to  facilitate  the  work  of  digestion  in  the  stomach, 
even  when  the  secretion  of  the  gastric  juice  is 
not  profoundly  impaired. 

The  exclusive  milk  diet,  so  often  advised  in  the 
treatment  of  gastric  affections,  does  not  suit 
neurasthenics  affected  with  gastro-intestinal 


DIET.  245 

atony.  The  large  quantities  of  milk  taken  by 
patients  subjected  to  this  regimen  are  often  badly 
digested,  and  only  promote  dilatation  of  the 
stomach. 

We  must  now  consider  the  cases  in  which 
nervous  exhaustion  is  accompanied  and  compli- 
cated by  the  dyspeptic  state  that  M.  Bouveret 
has  described  under  the  name  of  the  serious  form 
of  gastro-intestinal  atony. 

Invalids  of  this  class  are  usually  thin;  they  take 
far  too  little  food ;  their  dyspeptic  disorders  are 
very  intense ;  their  gastric  secretion  is  most  often 
markedly  impaired,  and  chemical  examination  of 
the  gastric  juice  reveals  either  a  deficiency  of 
hydrochloric  acid,  which  is  the  most  frequent 
case,  or,  much  more  rarely,  an  excess ;  and 
some  are  affected  with  permanent  dilatation. 
If  general  treatment  of  the  nervous  asthenia 
be  sometimes  enough  to  improve  or  even  cure 
the  slight  form  of  gastro-intestinal  atony,  this 
no  longer  holds  good  when  the  severe  form  is 
concerned.  Strict  diet  and  local  treatment  are 
then  necessary  to  mitigate  the  disorder  of  the 
digestive  functions. 

The  first  condition  to  be  fulfilled  is  to  regulate 
the  diet  in  the  matters  of  the  quantity  of  food 
taken,  the  hours  of  meals,  and  the  choice  of 
aliments. 

As  to  the  number  of  meals,  we  agree  with  M. 
Bouchard,  M.  Hayem,  and  M.  Bouveret  that 


246  NEURASTHENIA. 

three  meals  a  day  are  enough.  Some  physicians, 
with  the  object  of  lightening  the  work  of  digestion, 
and  thereby  the  dyspeptic  disorders  that  it  causes, 
advise  an  increased  frequency  in  the  taking  of 
food  with  a  diminution  in  the  amount  ingested  on 
each  occasion.  This  practice  must  be  set  aside, 
because  it  is  necessary  for  a  stomach  whose 
secretions  are  diminished  and  whose  motility  is 
weakened  to  have  sufficiently  prolonged  periods 
of  rest,  in  order  that  when  digestion  and  the 
evacuation  of  the  chyme  are  completed  it  may 
retract  and  be  in  a  fit  state  to  receive  new  food. 
And  if  the  aliments  ingested  be  too  copious  as 
well  as  taken  at  too  short  intervals,  then  it  is  easy 
to  conceive  that  the  activity  of  the  disordered 
stomach,  being  incessantly  solicited,  will  soon 
become  exhausted,  and  that  permanent  dilatation, 
followed  by  gastric  stasis  and  the  fermentation 
of  the  remnants  left  behind  in  the  organ,  may  be 
caused  or  aggravated  by  such  a  regimen. 

The  indications  as  to  the  distribution  of  hours 
of  meals  that  have  been  formulated  by  M. 
Bouchard  in  dealing  with  the  treatment  of  dilata- 
tion of  the  stomach,  are  perfectly  applicable  to 
the  severe  form  of  gastro-intestinal  atony  in 
neurasthenics.  The  morning  meal  should  be 
taken  about  seven  or  eight  o'clock ;  that  of  mid- 
day should  be  the  most  important ;  and  that  of 
the  evening,  taken  at  seven  o'clock,  should  be  less 
copious  than  the  mid-day  meal.  It  is  necessary 


DIET.  247 

that  this  long  interval  of  six  or  seven  hours 
between  the  second  and  third  meals  be  regularly 
respected ;  for  in  old-standing  or  severe  cases 
gastric  digestion  is  hardly  finished  at  the  end  of 
this  time.  Hence  the  patient  must  abstain  from 
food,  and  so  far  as  possible  from  drink,  during  the 
intervals.  After  lunch  it  is  usually  advantageous 
for  the  invalid  to  take  a  short  walk  at  a  slow  pace. 
Similarly  he  must  not  go  to  bed  till  about  three 
hours  after  the  evening  meal ;  for  absolute  rest 
and  sleep  seem  to  hinder  the  work  of  digestion, 
at  least  in  the  majority  of  cases. 

The  patients  must  be  advised  to  spend  plenty 
of  time  over  their  meals,  so  that  the  mastication 
and  insalivation  of  the  food  may  be  complete ; 
those  who  are  afflicted  with  defective  teeth  must 
have  recourse  to  artificial  teeth,  or  else  take  care 
to  have  all  their  solid  food  minced.  The  hygiene 
of  the  mouth  must  also  be  attended  to ;  all 
dyspeptics  should  brush  their  teeth  and  rinse 
their  mouths  with  a  slightly  antiseptic  solution 
before  and  after  every  meal. 

Choice  of  food. — A  mixed  and  varied  diet  is 
always  preferable  to  exclusive  diets.  Since  these 
patients  are  for  the  most  part  either  deficient  or 
totally  wanting  in  hydrochloric  acid,  as  is  shown 
by  methodical  chemical  examination  of  the  con- 
tents of  their  stomachs,  they  must,  as  in  the 
benign  form  of  gastro-intestinal  atony,  but  still 
more  rigorously,  be  enjoined  to  use  foods  that 


248  NEURASTHENIA. 

are  easy  of  digestion  and  little  liable  to  undergo 
acid  fermentations.  We  have  already,  in  dealing 
with  slight  atonic  dyspepsias,  indicated  the 
greater  number  of  these  foods  that  are  to  be 
selected,  and  it  is  necessary  that  they  figure  to 
the  exclusion  of  all  other  alimentary  substances 
in  the  diet  list  of  the  neurasthenics  with  whom 
we  are  now  concerned.  We  must  especially  put 
aside  from  this  mixed  regime  complicated  and 
highly-flavoured  preparations,  uncooked  sub- 
stances, certain  starchy  vegetables,  foods  that 
are  too  fat,  old  cheese,  in  short,  all  matters  that 
ferment  easily  in  a  stomach  devoid  of  free  hydro- 
chloric acid.  Fats,  however,  must  not  be  com- 
pletely excluded  from  the  dietary  of  neurasthenics, 
even  in  the  severe  form  of  atonic  dyspepsia.  But 
a  very  moderate  use  of  them  should  be  prescribed, 
for  a  time  at  least,  and  preference  should  be 
given  to  the  fat  of  beef  and  mutton  and  to  strictly 
fresh  butter.  The  usual  condiments  (salt,  pepper, 
mustard)  are  to  be  permitted,  but  in  moderate 
quantities. 

As  to  the  liquids  to  be  drunk,  the  regulations 
that  we  have  already  formulated  in  dealing  with 
the  first  degree  of  nervo-motor  dyspepsia,  are  in 
all  respects  applicable  here  also.  Warm  drinks 
may  be  given  with  advantage,  such  as  weak  tea, 
or  infusion  of  camomile  or  lime  flowers. 

It  is  in  this  severe  form  of  atonic  dyspepsia 
that  the  restriction  in  the  amount  of  food  taken 


DIET.  249 

that  we  have  already  mentioned,  is  frequently 
practised  by  the  sufferers.  When  left  to  them- 
selves they  eat  less  and  less,  because  they  observe 
that  a  very  slight  meal  is  followed  by  less  malaise, 
and  this  is  very  often  one  of  the  principal  causes, 
if  not  the  only  cause,  of  their  emaciation  and  loss 
of  strength.  Hence  the  physician  must  watch 
attentively  over  the  daily  amount  taken  by  the 
patient,  must  raise  it  little  by  little  to  the  normal 
quantity,  and  must  convince  the  patient  of  the 
necessity  of  taking  sufficient  food  even  at  the 
price  of  some  suffering.  It  is  in  cases  of  this 
class,  which  are  especially  grave  and  frequent  in 
the  neurasthenia  of  women,  that  Weir  Mitchell's 
treatment  by  means  of  progressive  alimentation 
may  render  the  greatest  services.  However,  we 
do  not  think  that  the  dietary  formulated  by  that 
physician  is  applicable  indifferently  to  all  cases  of 
inveterate  neurasthenia  with  serious  gastro-in- 
testinal  atony.  Its  use  should  be  reserved,  we 
think,  for  certain  cases  of  nervous  exhaustion 
whose  characters  we  shall  indicate  precisely 
when  we  explain  Weir  Mitchell's  systematic 
treatment,  and  the  therapeutics  of  the  neuras- 
thenia of  women.  The  mixed  regimen  that  we 
have  just  indicated  seems  to  us,  in  short,  to  be 
preferable  to  the  different  forms  of  treatment  by 
fattening,  and  to  all  partial  or  exclusive  dietaries, 
in  treating  the  majority  of  neurasthenics  affected 
with  gastro-intestinal  atony. 


250  NEURASTHENIA. 

Drugs. — These  patients  have  almost  all  swal- 
lowed the  most  varied  pharmaceutical  prepara- 
tions without  deriving  any  benefit  from  them  : 
digestive  wines,  absorbent  powders,  bicarbonate 
of  soda,  etc.  The  greater  number  of  these  drugs 
are  useless  or  injurious,  and  ought  to  be  prohibited. 
Alkalies  especially  are  generally  contra-indicated 
in  gastro-intestinal  atony,  which  is  often  accom- 
panied by  an  appreciable  diminution  in  the  free 
hydrochloric  acid  of  the  gastric  juice.  However, 
if  they  are  taken  some  time  (three-quarters  of  an 
hour  or  an  hour)  after  meals  in  the  form  of 
bicarbonate  of  soda  or  Vichy  water  warmed  in  a 
water-bath,  they  afford  marked  relief  to  the 
patient  in  some  cases.  The  commercial  pepsines 
have  about  the  same  therapeutic  value  as  inert 
powders. 

Pancreatine  has  perhaps  some  efficacy. 

The  drug  that  should  most  commonly  be 
prescribed  in  the  gastro-intestinal  atony  of 
neurasthenics  is  Hydrochloric  Acid.  It  augments 
to  a  certain  degree  the  digestive  power  of  the 
gastric  juice,  and  at  the  same  time  it  acts  as  an 
antiseptic  and  moderates  secondary  acid  fermen- 
tations. It  may  be  ordered  in  the  form  of  a 
watery  solution  of  the  strength  of  3  or  4  in  1000, 
in  doses  of  a  quarter  or  half  a  tumblerful  half-an- 
hour  after  the  mid-day  and  evening  meals.1 

1  This  is  practically  equivalent  to  9  to  12  drops  of  the  Acidum 
Hydrochloricum  dilutum  B.  P.  in  a  quarter  of  a  tumblerful  of  water, 
or  18  to  24  drops  in  half  a  tumblerful. — Trans. 


DIET.  251 

Electricity  has  been  applied,  especially  in  Ger- 
many, to  the  treatment  of  the  gastric  atony  of 
neurasthenics.  It  has  naturally  been  thought 
that  electric  currents  might  stimulate  both  the 
motility  and  the  secretion  of  the  stomach  ;  and 
sometimes  the  continuous  current,  sometimes 
faradisation,  has  been  employed  for  this  purpose. 
It  has  generally  been  in  cases  of  atony  with 
dilatation  that  electrical  treatment  has  been 
utilised.  Ziemssen,  Erb,  Leube,  and  in  France 
M.  Bouveret,  have  obtained  some  favourable 
results  from  it.  The  following  is  Erb's  method1 
of  applying  electricity  to  the  walls  of  the  stomach. 
He  places  a  large  electrode  over  the  spinous 
processes  at  the  level  of  the  cardia ;  the  other 
electrode  is  smaller  and  is  moved  over  the  anterior 
wall  of  the  stomach.  If  the  galvanic  current  be 
employed,  the  positive  pole  is  used  as  the 
posterior  electrode,  and  the  negative  pole  as  the 
labile  electrode.  If  faradism  be  employed,  it  is 
necessary  that  the  current  be  intense  enough  to 
provoke  a  somewhat  energetic  contraction  of  the 
abdominal  muscles  every  time  the  epigastrium  is 
touched.  The  sittings  should  be  daily,  should  last 
eight  to  ten  minutes,  and  should  take  place  either 
before  a  meal  or  after  washing  out  the  stomach 
if  the  patient  be  subjected  to  this  treatment. 

Ziemssen2  recommends  the  use  of  very  large 

1  Erb,  Handbook  of  Electrotherapeutics. 

2  Ziemssen,  Klinische  Vortrdge,  Leipzig,  1888,  quoted  by  Bouveret 
in  Traits  de  la  neurasthenic,  1891. 


252  NEURASTHENIA. 

electrodes,  8  to  10  inches  in  diameter,  of  which 
one  should  be  applied  to  the  abdominal  wall  at 
the  level  of  the  pylorus,  towards  the  great  cul-de- 
sac  of  the  stomach,  the  other  at  the  same  level 
behind,  a  little  to  the  left  of  the  spinal  column. 
The  large  area  of  these  electrodes  insures  the 
penetration  of  the  current.  The  constant  current 
is  used,  the  positive  pole  being  placed  behind,  and 
the  negative  in  front,  and  strong  contractions  of 
the  muscles  of  the  abdominal  wall  and  back  are 
set  up  by  moving  the  commutator.  The  sittings 
last  from  ten  to  fifteen  minutes. 

It  has  also  been  proposed  to  pass  one  of 
the  electrodes  into  the  cavity  of  the  stomach, 
into  which  a  certain  quantity  of  slightly  saline 
water  has  first  been  introduced.  But  this  pro- 
cedure has  the  disadvantage  of  being  borne 
with  difficulty  by  the  patient,  and  should  be 
rejected. 

Washing  out  the  stomach  should  not  be  erected 
into  a  routine  method  of  treatment  of  gastric 
atony,  as  some  physicians  seem  to  believe. 
Recourse  should  be  had  to  it  only  in  cases  of 
atony  with  acid  fermentation.  Washing  out  the 
gastric  cavity  is  certainly  a  good  therapeutic 
method,  but  its  use  should  be,  so  to  speak,  inci- 
dental, because  its  effect  is  only  upon  an  inter- 
current  complication  of  gastric  atony,  namely 
stasis  and  secondary  fermentations  of  the 
remnants  of  the  food. 


DIET.  253 

Neurasthenia  and  hyperchlorhydria. — When 
enumerating  the  different  dyspeptic  conditions 
that  may  exist  in  the  subjects  of  nervous 
exhaustion,  we  saw  that  increase  in  the  gastric 
secretion  of  hydrochloric  acid,  either  permanent 
or  intermittent,  was  sometimes  associated  with 
the  neurasthenic  group  of  symptoms.  Cases  of 
this  kind  are  indeed  very  rare,  and  it  may  be  said 
that  among  neurasthenic  dyspeptics,  as  among 
dyspeptics  generally,  neurasthenic  or  not,  absence 
or  insufficiency  of  hydrochloric  acid  is  the  rule, 
excess  the  exception.  None  the  less  is  it  true 
that  every  neurasthenic  in  whom  methodical 
analysis  of  the  gastric  juice  reveals  the  existence 
of  hyperchlorhydria,  should  be  placed  upon  a 
dietetic  regimen  appreciably  different  from  that 
suited  to  neurasthenics  who  suffer  from  gastro- 
intestinal atony  with  a  normal  reaction  or  with 
deficiency  of  hydrochloric  acid. 

In  cases  of  simple  hyperchlorhydria  it  is 
evidently  necessary  to  banish  from  the  dietary  all 
liquid  or  solid  ingesta  of  a  nature  to  stimulate 
the  gastric  mucous  membrane.  There  must  be 
prohibition  of  tea,  coffee,  liqueurs,  sauces,  and  all 
strongly  spiced  dishes,  condiments,  etc.  Very 
little  salt  must  be  added  to  the  food.  By  reason 
of  the  chemical  qualities  of  the  gastric  secretion, 
nitrogenous  foods  are  digested  best ;  for  it  is 
they  that  combine  with  the  greatest  amount  of 
free  hydrochloric  acid.  Hence  the  greater 


254  NEURASTHENIA. 

number  of  meats  should  enter  into  the  diet ;  but 
they  should  be  cooked  simply,  boiled,  roasted,  or 
braised.  Eggs  should  also  be  recommended  to 
those  suffering  from  hyperchlorhydria.  The 
majority  of  fats  and  starchy  foods  are  usually 
well  digested  by  these  patients,  and  their  diet,  in 
spite  of  the  ease  with  which  they  digest  meats, 
should  not  be  exclusively  nitrogenous.  It  ought 
to  approach  as  closely  as  possible  to  the  mixed 
diet. 

The  stomach  is  generally  neither  atonic  nor 
dilated  in  the  case  of  neurasthenics  with  hyper- 
chlorhydria. Stasis  and  secondary  acid  fermenta- 
tions are  hardly  to  be  feared  in  them ;  hence  it  is 
not  necessary  to  limit  the  amount  they  drink. 
Pure  water  and  milk  largely  diluted  with  water 
should  be  preferred  to  spirituous  liquors  which 
excite  too  energetic  a  hypersecretion  on  the  part 
of  the  mucous  membrane,  and  may,  even  in  very 
small  doses,  provoke  gastric  pains.  Kefir  and 
cider  are  better  borne. 

The  action  of  alkalies  is  eminently  beneficial 
here.  Bicarbonate  of  soda  should  be  prescribed 
to  the  amount  of  45  to  90  grains  after  the  mid- 
day and  the  evening  meal.  This  quantity  may 
be  administered  in  two  equal  parts  separated  by 
an  hour's  interval ;  the  first  should  be  given 
about  two  hours  after  the  meal,  that  is  to  say 
at  the  time  when  the  gastric  pains  are  expected. 
This  drug,  however,  though  it  has  a  soothing 


DIET.  255 

effect  for  the  time,  may  eventually  increase 
the  acid  secretion  of  the  stomach.  Hence  it  is 
usually  better  to  substitute  magnesia  or  chalk 
for  it,  or  to  combine  them  with  it. 

The  stomach  should  not  be  washed  out  in  the 
treatment  of  simple  hyperchlorhydria  without 
hypersecretion,  because  the  phenomena  of  reten- 
tion and  gastric  dilatation  are  absent  in  this  form 
of  dyspepsia. 

As  to  hyperchlorhydria  with  permanent  or 
intermittent  hypersecretion,  we  cannot  deal  with 
it  here.  Reichmann's  disease  is  in  fact  too 
exceptional  a  complication  of  neurasthenia  for 
us  to  set  forth  its  treatment  and  dietary  without 
overstepping  excessively  the  limits  of  our  subject. 

Up  to  the  present  we  have  considered  the 
alimentary  hygiene  and  the  various  regimens  that 
neurasthenics  should  be  subjected  to,  with  a  view 
to  attenuating  or  curing  the  dyspeptic  disorders 
that  are  habitually  associated  with  nervous 
exhaustion.  Dietetics  may  also  be  called  on  to 
intervene  in  the  treatment  of  certain  neurasthenic 
conditions,  not  now  as  a  hygienic  measure 
destined  only  to  palliate  the  derangements  of  the 
digestive  functions  and  to  insure  the  nutrition  of 
the  patient  even  in  spite  of  those  derangements, 
but  also  as  a  means  of  regulating  or  reforming 
metabolism.  In  the  chapter  dealing  with  the 
etiology  of  nervous  exhaustion,  we  insisted  on 


256  NEURASTHENIA. 

the  close  relationship  between  neurotic  and 
arthritic  states.  We  saw  in  particular  that  the 
acid  or  uric  diathesis  constituted  a  soil  especially 
favourable  for  the  development  of  neurasthenia, 
and  furthermore  that  there  were  cases  in  which 
the  neurasthenic  group  of  symptoms  seemed  to 
have  sprung  up  under  the  sole  influence  of  that 
arthritic  diathesis.  Thus  gout  is  sometimes 
complicated  by  nervous  asthenia,  not  from  the 
result  of  a  pure  coincidence,  but  because  the 
neurasthenic  condition  has  been  started  and  kept 
up  by  the  gout  itself.  It  is  clear  that  cases  of 
this  kind  need  a  special  treatment,  and  that  the 
dietary  to  be  instituted  should  be  specially 
directed  against  the  uric  acid  diathesis.  Similarly, 
when  neurasthenia  is  associated  with  obesity, 
there  may  be  advantage  in  modifying  first  of  all 
the  general  metabolism  of  the  patient  so  as  to 
free  him  from  his  overburden  of  fat.  What 
then  are  the  dietaries  to  be  prescribed  in  such 
cases  ? 

Gout  and  Neurasthenia. — It  is  only  when  a 
gouty  neurasthenic  exhibits  no  serious  dyspeptic 
derangements,  when  he  is  suffering  from  the 
slight  form  of  gastro-intestinal  atony  or  from 
simple  hyperchlorhydria,  that  it  is  justifiable  to 
put  him  on  a  diet  strict  enough  to  modify  his 
disordered  metabolism.  In  the  contrary  case  it 
is  absolutely  necessary  to  endeavour  first  to 
improve  the  state  of  his  digestive  functions. 


DIET.  257 

Hence  the  dietary  that  we  are  about  to  lay  down 
here  is  more  especially  applicable  to  gouty 
subjects  who  are  plethoric  and  vigorous,  and 
whose  stomachs  are  still  good.  In  fact,  an 
excessive  sobriety,  a  too  rigorous  regimen  of 
starvation  should  not  be  prescribed  even  to  young 
and  robust  sufferers  from  gout,  and  it  is  prudent 
not  to  make  too  abrupt  an  alteration  in  their 
dietary.  Otherwise  there  would  be  a  risk  of 
depressing  their  strength,  of  aggravating  their 
nervous  asthenia,  and  of  transforming  into  atonic 
gout  their  hitherto  florid  type  of  the  disease. 
Consequently  exclusive  diets  and  forms  of  treat- 
ment by  starvation  should  be  avoided. 

Among  others,  Cantani's  regimen  should  be 
rejected,  as  it  is  merely  a  starvation  treatment. 
Cantani  allows  only  soup,  meat,  eggs,  and  fish, 
and  in  small  quantities.  He  absolutely  prohibits 
fats  and  carbohydrates,  and  on  the  other  hand 
orders  green  vegetables  in  great  abundance. 
Finally  he  advises  the  gouty  never  to  eat  to 
satiety.  It  is  evident  that  such  a  dietary  cannot 
be  followed  long  without  weakening  the  patient 
exceedingly. 

Absolute  vegetarianism  must  be  discoun- 
tenanced for  reasons  already  given. 

An  exclusive  milk  diet  is  a  regimen  of  relative 
starvation.  It  may  render  real  service,  but  it 
should  not  be  continued  for  long.  It  should  only 
be  prescribed  for  short  periods  of  five  or  six  days 

Neurasthenia.  17 


258  NEURASTHENIA. 

at  a  time.  In  this  form  it  is  a  useful  mode  of 
treatment,  because  it  increases  the  secretion  of 
urine  and  washes  out  the  organism. 

The  diet  of  gouty  neurasthenics,  like  that  of 
neurasthenics  free  from  uricaemia,  should  be 
mixed.  Nitrogenous  foods,  fats  and  carbohy- 
drates should  all  enter  into  its  composition  ;  but 
the  quantity  and  the  quality  of  these  alimentary 
substances  must  be  regulated. 

The  gouty  patient  must  be  very  cautious  in  the 
use  of  meat.  He  must  eat  white  meats  by 
preference,  as  these  are  less  stimulating  and  less 
rich  in  albuminoids  than  red  meats.  Munk  and 
Uffelmann  have  shown  that  animal  albumen  does 
not  form  more  than  three-quarters  of  the  total 
albumen  in  a  normal  diet.  This  proportion  may 
be  lowered  to  two-thirds  and  even  to  half  in  the 
diet  of  the  gouty,  but  it  will  be  best,  especially  at 
first,  to  prescribe  the  daily  consumption  of  a 
quart  of  milk,  which  will  approximately  compen- 
sate for  the  loss  of  albuminoid  matter  resulting 
from  the  restricted  use  of  meat. 

In  the  matter  of  fats  and  carbohydrates  re- 
striction is  equally  necessary  (Bouchard) ;  but 
here  opportunism  is  indispensable.  The  allowance 
of  these  substances  must  be  proportionate  to  the 
activity  displayed,  to  the  energy  expended  daily  by 
the  patient ;  the  latter  must  in  any  case  preserve 
a  certain  amount  of  plumpness,  and  his  weight 
must  remain  in  correspondence  with  his  stature. 


DIET.  259 

In  general,  gouty  subjects  should  make  free 
use  of  green  vegetables,  carrots,  turnips,  and 
cauliflowers,  should  be  very  moderate  in  their 
consumption  of  potatoes,  and  should  abstain  as 
far  as  possible  from  farinaceous  seeds  (lentils, 
beans,  peas)  and  doughy  foods,  which  are  much 
richer  in  carbohydrates. 

From  the  dietary  of  the  gouty  must  further  be 
excluded  tomatoes,  sorrel,  spinach,  asparagus, 
and  rhubarb,  all  too  rich  in  oxalic  acid  ;  gherkins 
and  all  sorts  of  pickles.  M.  Lecorche  also  pro- 
hibits the  use  of  gooseberries,  strawberries, 
raspberries,  apples  and  pears,  which  are  too  acid. 
He  allows  peaches,  plums,  and  grapes  in  small 
quantities.  Sugared  fruits  and  sugar  in  general 
are  only  permitted  in  small  amounts. 

Is  it  beneficial  for  the  gouty  neurasthenic  to 
drink  a  large  quantity  of  water  ?  Does  the 
ingestion  of  this  liquid  promote  the  elimination 
of  uric  acid,  or  has  it  no  such  influence  ?  Experi- 
mental researches  undertaken  on  this  subject 
have  led  the  investigators  (Geuth  and  Henitz, 
Schondorff,  etc.)  to  contradictory  results.  How- 
ever this  be,  clinical  experience  has  shown  that 
increased  diuresis  always  facilitates  depuration 
by  the  urine,  and  it  is  known  that  treatment  by 
waters  that  are  almost  indifferent  as  regards 
their  mineral  constituents  has  a  very  beneficial 
action  on  the  gouty.  These  patients  should  then 
be  permitted  a  large  allowance  of  water,  either 


260  NEURASTHENIA. 

pure  or  with  the  addition  of  a  small  quantity  of 
Bordeaux. 

It  is  necessary  to  forbid  the  use  of  generous 
wines,  of  liqueur  wines,  of  liqueurs,  of  beer,  and 
of  cider.  Tea  and  coffee  are  to  be  allowed,  but 
only  once  a  day,  and  in  small  amount. 

As  to  the  dietary  of  obese  neurasthenics,  it  will 
be  found  in  the  volume  of  this  collection  that 
deals  with  obesity ; l  we  could  not  give  the  details 
here  without  passing  beyond  the  limit  that  we 
have  laid  down. 

Diet  for  a  neurasthenic  affected  with  gastric 
atony  of  moderate  intensity. 

Three  meals :  breakfast  at  8,  lunch  at  noon, 
dinner  at  7 ;  afternoon  tea  at  4  o'clock  optional. 

BREAKFAST    (8    O'CLOCK). 

a.  Half  a  pint  of  milk  with  the  addition  of  a 
little  coffee,  tea  or  cocoa.     Toast  with  a  little 
fresh  butter. 

b.  Two  eggs  lightly   boiled;    a  cup   of  tea; 
toast. 

c.  Oatmeal  or  rice  flour,  either  boiled  in  milk 
or  water,  or  beaten  up  into  a  cream  with  milk  and 
the  yolks  of  two  eggs. 

d.  Kefir  No.  2  (medium  strength).     The  use 
of  this  must  not  be  prolonged  for  more  than  15 

i  Hygiene  dcs  obeses   (Prof.    Proust  and  Dr.  A.  Mathieu),  Paris, 
Masson. 


DIET.  261 

consecutive  days,  after  which  one  of  the  other 
breakfasts  must  be  reverted  to  temporarily. 

LUNCH  (NOON). 

This  meal  may  consist,  as  the  patient  prefers, 
of  either : 

1.  One  meat  dish;    one   vegetable,   eggs,  or 
vermicelli   or   macaroni  ;    one   or  two   kinds   of 
dessert1;  or 

2.  One  dish  of  eggs  or  fish;  one  dish  of  meat; 
one    vegetable,    or    macaroni   or    some    similar 
doughy  food  ;  one  or  two  kinds  of  dessert. 

The  dishes  are  to  be  chosen  among  the  fol- 
lowing : 

Eggs  lightly  boiled,  or  broiled,  or  in  an  omelet 
soft  and  slightly  cooked  with  butter  in  a  pan 
lined  with  yolk  of  egg,  and  with  a  little  fresh 
butter  added  at  the  moment  of  serving. 

Fish  (sole,  whiting,  skate,  pike,  perch,  fresh 
water  trout),  which  must  be  quite  fresh.  Cooked 
in  court-bouillon  with  water2  or  grilled  or  fried. 
The  skin  not  to  be  eaten.  The  fish  may  be 
accompanied,  if  desired,  by  a  sauce  which  should 
consist  only  of  eggs,  milk,  cream,  flour,  uncooked 
butter  ;  it  should  be  seasoned  with  salt  or  lemon. 

Oysters :  moderately  plump. 

Beef  or  Mutton,  lean,  with  the  fibrous  tissue 
and  fat  carefully  removed,  grilled  or  roasted 

1  In  the  French  sense — see  next  page. — Trans. 

2  Court  bouillon  consists  of  vinegar  or  wine  with  parsley,  laurel, 
and   other   herbs ;   the  fish  is  cooked  in  it  and  it  is  then  thrown 
away — not  used  as  sauce. — Trans. 


262  NEURASTHENIA. 

(without  the  gravy) ;  cold  braised  meat,  not  larded ; 
brain  and  sweetbread1  cooked  with  wine  sauce  and 
with  fresh  butter  added  at  the  moment  of  serving, 
or  flavoured  with  lemon  juice ;  calf's  tongue ; 
lean  ham  (York  or  Westphalia). 

Fowl  boiled  and  served  in  the  liquid  with  coarse 
salt,  or  roasted  (without  the  skin  or  gravy),  or 
cooked  in  court-bouillon  with  water,  and  with 
carrots,  onions,  and  fine  herbs ;  galantine  of  fowl 
without  the  jelly. 

Game :  fresh  pheasant  or  young  partridge  boiled 
or  roasted  (without  the  skin  or  gravy). 

Vegetables  :  potatoes  cooked  in  hot  cinders,  or 
boiled  or  baked  (without  the  skin)  ;  well  strained 
purees  of  potatoes,  peas,  lentils,  kidney-beans, 
prepared  with  soup  or  with  milk  to  which  the 
yolk  of  an  egg  may  or  may  not  be  added  ;  chicory, 
lettuce,  spinach  cooked  in  milk  or  in  its  juice  ; 
cauliflower  in  well  strained  purees ;  asparagus 
with  sauce  made  of  cream  or  eggs ;  artichokes 
with  white  sauce  containing  no  cooked  butter 
celery  in  its  juice ;  fine  French  beans,  or  peas, 
stewed  and  with  the  addition  of  fresh  butter. 

Milk  puddings  with  little  sugar. 

Dessert :  mild  cheese  (cream  cheese,  new  Brie, 
slightly  salted  cheese) ;  dry  cakes,  cooked  fruit 
with  little  sugar  ;  small  quantities  of  plums  (very 
ripe),  or  peaches,  grapes  or  oranges. 

1  The  advisability  of  giving  food  rich  in  purins  to  neurasthenics 
seems  doubtful. — Trans. 


DIET.  263 

Bread :  in  small  quantity ;  preferably  crusts  or 
toast.  The  crumb  to  be  avoided,  especially  of 
new  bread. 

Beverages:  two  glasses1  at  most,  preferably 
less.  Alet  or  Evian  water,  either  pure  or  with  the 
addition  of  a  little  white  Bordeaux ;  or  weak  beer, 
or  malt  beer  diluted  with  f  water  ;  or  by  prefer- 
ence very  hot  infusions  (weak  tea,  camomile,  lime 
flowers,  orange  flowers). 

Coffee  ;  if  the  patient  is  in  the  habit  of  taking 
this,  he  may  have  a  small  coffee-cupful,  after 
lunch  only. 

AFTERNOON    TEA    (4    O'CLOCK). 

Dry  cakes  and  a  cup  of  hot  tea ;  or  a  cup  of 
milk  with  cocoa  or  phosphatine. 

DINNER  (7  O'CLOCK) 

This  meal  is  to  be  composed  of  soup,  one  dish 
of  meat,  one  dish  of  vegetables  or  such  doughy 
foods  as  macaroni,  one  or  two  kinds  of  dessert. 
The  meat  may  be  replaced  by  fish  or  by  eggs. 

The  soup  should  be  made  of  vegetables  without 
meat — of  wheat,  oatmeal,  peas,  beans,  lentils, 
rice,  semolina  or  dough,  prepared  with  water, 
eggs  or  milk. 

The  other  articles  are  to  be  selected  from  the 
list  given  for  lunch. 

Articles  of  food  specially  prohibited. 

Hors  d'oeuvre. 

Spices  (mustard,  pepper,  gherkins). 

1  Say  12  oz.— Trans. 


264  NEURASTHENIA. 

Lobsters,  shrimps,  crayfish,  shellfish. 

"  High  "  game.  Game  with  dark  flesh.  Potted 
foods. 

Fat  meat.  Foie  gras.  Fishes  with  much  fat 
(eel,  salmon,  herring,  mackerel). 

Pork-butcher's  meat,  except  lean  ham. 

Sauces  in  general,  especially  if  spiced  or 
greasy. 

Cabbage ;  cauliflowers,  except  in  puree ;  sorrel, 
tomatoes,  onions,  turnips. 

Raw  vegetables  (melon,  salad,  radish,  cucum- 
ber). 

Fried  potatoes  and  fried  food  in  general  ex- 
cept fish,  which  may  be  eaten  if  the  skin  is 

removed. 

« 

Ripened  cheese. 

Raw  fruit  (except  plums,  peaches,  oranges  or 
grapes,  if  very  ripe). 

Sweets,  greasy  pastry,  cakes. 

III. 

The  diet  required  in  Intestinal  Disorders. — 

Constipation. — Enteroptosis, — Atony  and 

Spasm.  —  Muco  -  Membranous 

Colitis. — Their  Treatment. 

Intestinal  disorders  are  commonly  associated 
with  the  gastric  symptoms  in  neurasthenia.  Con- 
stipation is  very  frequent,  especially  in  female 
patients.  Though  it  is  sometimes  slight  and  easy 


DIET.  265 

x 

to  overcome,  more  often  it  is  resistant  and  ten- 
acious ;  the  patients  complain  that  their  bowels 
do  not  move  naturally,  and  that  they  are  obliged 
to  have  recourse  to  artificial  means  to  make 
them  act.  This  constipation,  which  is  simple 
and  painless  in  some  cases,  is  at  times  accom- 
panied by  flatulence  and  borborygmi,  especially 
on  waking  in  the  morning.  In  exceptional  cases 
the  patients  take  no  notice  of  it ;  more  com- 
monly they  worry  themselves  about  it,  and  are 
more  affected  by  it  than  is  good  for  them, 
attributing  to  it,  not  always  without  reason,  the 
flushes  of  heat  to  the  face,  the  occasional  vertigo, 
the  respiratory  embarrassment,  and  the  abdominal 
discomfort  from  which  they  suffer.  It  not  rarely 
happens  that  the  constipation  is  -interrupted  by 
short  attacks  of  diarrhrea ;  the  stools  are  then 
liquid  or  soft,  and  unload  the  intestines  only  very 
incompletely,  leaving  it  more  or  less  distended  by 
hardened  faeces,  which  are  passed  later  with  the 
aid  of  laxatives.  There  is  rather  a  false  diarrhoea 
than  a  true  one.  The  usual  diet  of  neurasthenics 
is  not  of  a  nature  to  lessen  this  trouble;  milk, 
unless  it  is  badly  digested,  grilled  meats,  and 
starchy  and  doughy  foods  leave  little  residue,  so 
that  contraction  of  the  intestinal  walls  is  not  set 
up  by  undigested  portions  of  the  food,  and  the 
atony  is  thus  increased.  Rest  in  the  horizontal 
position,  especially  prolonged  rest  in  bed  when 
that  is  prescribed,  also  contributes  its  share  in 


266  NEURASTHENIA. 

keeping  up  the  sluggishness  of  the  intestines. 
However,  contrary  to  what  was  long  believed, 
the  constipation  of  neurasthenics  is  not  always 
due  to  atony.  In  many  cases  it  depends  on 
spasm  of  the  intestine.  Fleiner,  who  called 
attention  to  this  spasmodic  constipation,  thinks 
that  it  is  the  most  habitual  form  in  neurasthenics, 
atonic  constipation  being  more  particularly  the 
appanage  of  old  age.1  The  clinical  examination 
of  patients  justifies  the  view  taken  by  Fleiner ; 
for  it  is  fairly  common  to  observe  by  palpation 
that  the  large  intestine  is  reduced  to  the  width 
of  the  little  finger,  hard,  and  contracted,  and  that 
it  can  be  rolled  under  the  hand  when  the  iliac 
fossa  is  examined,  especially  on  the  left  side, 
forming  the  sigmoidal  cord  to  which  Glenard 
called  attention  in  his  description  of  enteroptosis. 
It  is  not  proved,  however,  that  it  is  correct  to 
oppose  spasmodic  to  atonic  constipation  as 
decidedly  as  Fleiner  does ;  Mathieu2,  indeed,  has 
shown  that  the  two  forms  may  co-exist,  the 
bowel  being  contracted  in  its  descending  part, 
while  on  the  other  hand  it  is  atonic  and  dilated 
at  its  origin  at  the  caecum.  However  this  be,  we 
must  not  lose  sight  of  this  notion  of  a  spasmodic 
element  which,  in  the  majority  of  cases,  appears 
to  precede  the  atonic  element  and  to  surpass  it 
in  importance  ;  for  the  treatment  of  neurasthenic 

1  Fleiner,  Berlin**  Klin.  Wockenschrift,  1893. 

2  Mathieu,  Traite  des  maladies  de  Vestomac  et  de  I'intestin,  Paris,  1900. 


DIET.  267 

constipation  is  in  large  measure  dependent  on  it. 

If  it  is  a  good  hygienic  habit  for  everyone  to 
go  to  stool  at  a  regular  hour  every  day,  neuras- 
thenics ought  to  make  a  point  of  doing  so  still 
more  than  all  others.  Insufficient  motions 
promote  the  sluggishness  of  the  liver  and  the 
intestinal  fermentations  from  which  they  often 
suffer.  These  conditions  are  shown  by  the 
appearance  and  the  characters  of  the  fasces, 
which  are  passed  too  seldom,  and  which  are 
either  badly  coloured  (deficiency  of  bile)  or  black 
and  fqetid. 

But  it  is  no  easy  matter  to  contend  against  the 
constipation  of  neurasthenics,  at  least  if  we  may 
judge  from  the  list  of  aperients  of  which,  as  a 
rule,  the  patients  have  already  made  use  when 
they  come  to  consult  us.  In  fact  they  have  often 
exhausted  the  series  of  the  customary  laxatives 
of  the  pharmacopoeia,  not  to  mention  pharmaceu- 
tical specialties  or  those  whose  pompous  adver- 
tisements and  fantastic  exotic  titles  are  displayed 
at  length  on  the  last  page  of  the  newspapers. 
Out  of  all  this  arsenal  they  have  generally 
retained  one  or  two  drugs,  their  favourite  laxa- 
tives, which  seems  to  them  to  be  more  effectual 
than  the  others,  and  which  they  employ  with  an 
assiduity  that  they  deem  to  be  meritorious. 

In  this  matter  it  is  rarely  that  we  have  not  to 
change  the  habits  they  have  acquired,  which 
are  not  free  from  disadvantages ;  one  patient 


268  NEURASTHENIA. 

never  sits  down  to  table  in  the  evening  without 
first  swallowing  one  or  two  pills  of  some  prepar- 
ation of  aloes  or  cascara;  another  takes  his 
rhubarb  or  his  dose  of  Seidlitz  powder  regularly 
before  the  first  spoonful  of  soup,  or  swallows  in 
the  morning  his  capsules  of  castor  oil,  or  his  glass 
of  Carabana,  Montmirail,  or  Hunyadi  Janos 
water.  The  sluggishness  of  the  intestines, 
though  for  a  time  it  is  more  or  less  overcome, 
becomes  more  marked  on  this  regimen,  and  ends 
by  resisting  the  means  that  at  first  had  got  the 
better  of  it.  Then  the  stomach,  which  there  are 
so  many  reasons  for  being  careful  of  in  the  case 
of  neurasthenics,  cannot  always  stand  uncom- 
plainingly the  laxatives  that  are  meant  to  set  the 
intestines  in  action,  and  to  which  it  is  compelled 
to  furnish  a  passage. 

The  treatment  of  the  constipation  of  neuras- 
thenics— like  that  of  all  habitual  constipation, 
indeed — must  be  subjected  to  certain  rules. 
The  first  of  these  is  one  on  which  I  cannot 
insist  too  much. 

Drugs  must  be  employed  as  little  as  possible, 
and  recourse  must  be  had  in  the  first  place  to 
hygienic,  mechanical  and  physical  methods. 

One  succeeds  fairly  often — more  often  than 
might  be  thought — in  overcoming  the  intestinal 
atony  of  neurasthenia  by  correcting  the  bad 
habits  of  the  patients.  These  usually  wait  till  the 
need  makes  itself  felt  before  they  go  to  the  closet ; 


DIET.  269 

and  as  the  need  is  rare  and  by  no  means  urgent, 
and  as  the  possibility  of  delaying  the  satisfaction 
of  it  is  welcomed,  for  it  puts  off  a  small  duty 
which  interferes  somewhat  with  the  avocations 
of  a  busy  day,  many  neurasthenics  simply 
trust  to  their  morning  rhubarb  or  their  evening 
cascara,  and  await  the  calls  of  their  intestines 
patiently.  This  method  of  acting  is  deplorable, 
and  calculated  to  keep  up  the  constipation  ;  the 
patients  must  be  made  to  submit  to  a  quite 
contrary  practice.  They  must  be  required  to  go  to 
the  closet  at  a  fixed,  absolutely  fixed,  time,  always 
at  the  same  stage  of  their  dressing ;  as  soon,  for 
example,  as  they  have  put  on  their  trousers  or 
petticoats.  This  method  is  not  new.  Trousseau 
showed  the  efficacy  of  it,  and  he  was  probably 
not  the  first.  "  The  will,"  he  wrote,  "  and  a  patient 
"  and  regularly  applied  will,  usually  triumphs  over 
"  this  infirmity  "  (constipation).  "  Every  day, 
"  exactly  at  the  same  hour,  the  patient  must  go 
"  to  stool.  He  must  make  vigorous  efforts  during 
"  a  fairly  long  time,  and  if  these  efforts  prove 
"  ineffectual  he  must  wait  till  next  day,  even  if 
"  the  need  should  make  itself  felt  beforehand.  If 
"  there  is  no  motion  on  the  second  day,  after 
"  renewed  attempts,  he  must  at  once  take  an 
"  enema,  not  of  tepid  water,  but  of  water  merely 
"with  the  chill  off,  and  afterwards  with  cold 
"  water.  On  the  next  day  the  same  attempts  are 
"  to  be  renewed  and  to  be  put  off  till  the  morrow 


270  NEURASTHENIA. 

"  if  they  have  been  ineffectual,  and  on  this  second 
"  occasion  again  a  cool  enema  must  be  taken  if  no 
"  evacuation  has  been  obtained.  The  repetition 
"  of  the  act,  invariably  at  the  same  hour,  ends  by 
"  bringing  back  the  feeling  of  a  desire  to  pass  a 
"  motion  at  the  moment  when  the  patient  wishes 
"to  go  to  the  closet.  It  is  rarely  that  a  daily 
"  evacuation  fails  to  be  obtained  after  eight  or 
"  ten  days  of  these  patient  and  methodic  pro- 
"  ceedings." l 

I  have  quoted  this  passage,  for  it  would  be 
impossible  to  describe  better  the  technique  of  this 
re-education  of  the  intestine,  which  ought  to  be 
the  principal  aim  in  the  treatment  of  habitual 
constipation  ;  let  us  adhere  firmly  to  the  stool  at 
the  hour  fixed,  and  never  except  at  the  hour  fixed, 
unless,  it  is  hardly  necessary  to  say,  the  desire 
should  be  too  urgent  during  the  interval,  a  thing 
that  only  exceptionally  happens  to  such  a  degree 
in  cases  of  intestinal  atony.  I  make  a  reservation 
as  to  the  vigorous  effort  of  which  Trousseau 
speaks ;  this  is  useful  in  the  early  days  of  the 
treatment,  in  order  to  call  the  attention  of  the 
intestine,  but  later  constitutes  rather  an  element 
of  inhibition ;  a  time  comes  when  the  bowel  has 
acquired  the  habit,  and  defalcation  takes  place 
more  easily  if  it  is  automatic  and  reflex  than  if 
under  the  influence  of  the  will. 

The  effect  of  this  proceeding  may  be  further 

1  Trousseau,  Cliniqw  medicate  de  I' Hotel  Dieu,  5«  ed.,  t.  Ill,  p.  195. 


DIET.  271 

aided  by  taking  a  bunch  of  grapes  on  awaking,  or 
an  orange,  or  a  simple  glass  of  water,  if  the 
stomach  tolerates  them  well. 

Let  us  insist  on  this  method  first  and  foremost, 
and  at  the  same  time  let  us  impress  on  the  patient 
the  conviction  that  he  must  succeed.  It  must 
not  be  presented  to  him  as  a  plan  to  be  followed, 
in  case  of  failure,  by  other  and  more  effectual 
means.  This  would  diminish  its  chances  of  suc- 
cess. A  medical  man  who  can  gain  enough 
authority  over  his  patient  to  ensure  that  the 
attempt  is  made  with  good  faith  and  in  accordance 
with  the  rules  laid  down,  will  often — very  often — 
attain  his  object. 

The  result  may  be  promoted,  moreover,  by 
advising  some  gymnastic  exercises,  especially 
alternative  movements  of  flexion  and  extension  of 
the  body,  which  are  to  be  performed  by  the 
patients  for  four  or  five  minutes  every  morning 
on  getting  up,  and  again  in  the  evening  on  going 
to  bed.  Again,  a  compress,  folded  several  times 
and  soaked  in  cold  water,  should  be  applied  to  the 
epigastrium,  as  Trousseau  advised,  on  getting  up  in 
the  morning ;  it  should  be  covered  by  a  piece  of 
gutta-percha,  placed  between  it  and  the  clothes, 
and  should  be  left  in  position  for  three  or  four 
hours. 

If  regulating  the  hour  of  the  daily  motion, 
aided  or  not  by  the  methods  that  I  have  just 
indicated,  does  not  give  the  results  hoped  for, 


272  NEURASTHENIA. 

then,  and  then  only,  abdominal  massage  is  to  be 
combined  with  it ;  the  best,  and  really  the  only 
kind  to  recommend,  is  that  which  is  performed 
by  an  expert  masseur.  Moreover  he  must  make 
his  method  depend  on  the  nature  of  the  intestinal 
disorder;  vigorous  massage,  which  might  suit 
cases  where  atony  was  the  leading  feature, 
would  be  injurious  in  spasmodic  constipation. 
In  the  latter  cases  the  intestine  must  not  be 
stimulated  as  in  the  former,  but,  on  the  contrary, 
what  was  recently  called  a  "  contra-stimulant " 
action  must  be  produced ;  it  is  light  and  super- 
ficial friction,  or  effleurage,  that  is  effectual  in 
these  cases.1  Experience,  and  even  a  certain 
amount  of  skill,  are  necessary  to  do  this  well ; 
consequently  the  entreaties  of  some  ladies  to  be 
allowed  to  have  the  massage  done  by  their  maids, 
must  not  be  yielded  to  as  a  rule.  The  more  or 
less  clumsy  and  usually  rough  pressure  of  an 
inexpert  hand  may  indeed  diminish  atony;  but 
on  the  other  hand  it  is  injurious  if  there  is 
intestinal  spasm,  and  that,  as  was  pointed  out 
above,  is  the  rule.  For  similar  reasons  one  must 
dissuade  the  patients  from  adopting  methods 
which  allow  them  to  massage  themselves,  such 
as  the  spheres  or  cylinders  of  wood  or  metal 
which  may  be  found  in  shops,  and  which  are 
intended  to  be  rolled  along  the  course  of  the 
intestine  so  as  to  perform — more  or  less  well — 

1  Mazeran,  Presse  medicale,  1901. — Froussard,  These  de  Paris. 


DIET.  273 

the  work  of  the  masseur's  hand.  The  results 
obtained  from  them  are  usually  only  poor,  in  spite 
of  which  some  patients  become  the  slaves  of  the 
instrument,  and  persuade  themselves  that  they 
could  not  obtain  a  motion  unless  they  first  kneaded 
the  abdomen  in  this  way  for  a  considerable  time. 
It  must  be  remembered  that  the  neurasthenic 
easily  contracts  habits  from  which  he  finds  it 
difficult  to  free  himself,  and  we  must  endeavour 
to  inculcate  none  into  him  except  those  that  are 
simple  and  really  useful. 

Electricity  often  succeeds  when  regulating 
the  hour  of  the  motion  and  massage  have  not 
sufficed.  Failure  is  certainly  due  as  a  rule  to 
not  having  taken  enough  care  to  distinguish 
atonic  from  spasmodic  cases.  The  methods  that 
suit  the  one  are  not  those  that  should  be  used  for 
the  other. 

But  neither  massage  nor  electricity  is  always 
applicable.  They  are  not  within  the  reach  of 
patients  who  live  away  from  large  towns,  or 
whose  means  are  limited.  In  these  cases,  if  the 
methods  already  indicated  prove  ineffectual, 
recourse  must  be  had  to  those  I  am  about  to 
mention. 

Before  turning  to  laxatives  administered  by 
the  mouth,  which  try  the  stomach  more  or 
less,  we  should  recommend  enemata.  But  they 
must  be  given  with  discretion ;  if  enemata  are 
not  prescribed  at  suitable  hours  and  in  a  good 

Neurasthenia.  18 


274  NEURASTHENIA. 

form,  they  may  be  not  only  useless  but  harmful. 
The  injection  may  be  large  (a  pint)  or  small 
(half  a  pint);  it  may  be  simple,  that  is  to  say 
composed  of  water  only,  either  cold,  or  with  the 
chill  off,  or  hot,  taken  in  the  morning  a  few 
moments  before  the  time  for  going  to  stool  ; 
or  it  may  be  glycerinated,  i.e.  composed  of  a 
glassful  of  water  with  6  or  8  drachms  of 
glycerine,  given  at  the  same  time  as  the  last ; 
or  an  oil  injection,  of  15  to  20  ounces  of 
almond  or  olive  oil  taken  in  the  morning  ;  or 
again,  as  Mathieu  advises,  an  injection  of  four 
ounces  of  oil,  administered  at  bed-time,  retained 
during  the  night,  and  followed  in  the  morning 
by  an  injection  of  tepid  water,  with  the  object 
of  bringing  on  the  evacuation  ;  and  finally  we  may 
order  copious  irrigations  of  the  bowel.  These 
are  given  as  follows  :  3  to  4  pints  of  water, 
boiled  and  then  cooled  to  a  temperature  of  95° 
to  104°,  are  placed  in  a  glass  reservoir,  which 
is  provided  with  an  india-rubber  tube  having  a 
stop-cock  at  the  end.  The  patient  lies  on  his 
right  side  with  his  right  leg  straight  and  his 
left  thigh  flexed  at  the  hip-joint.  A  moderately 
soft  catheter  of  red  rubber  is  passed  for  a 
distance  of  4  to  6  inches  into  the  rectum,  the 
stopcock  is  adjusted,  and  the  water  is  allowed 
to  enter  the  intestine,  the  reservoir  being  kept 
at  a  height  which  should  not  exceed  20  inches. 
In  place  of  the  reservoir  it  is  often  more 


DIET.  275 

convenient  to  use  a  quart  bottle  furnished 
with  a  siphon. 

Some  knowledge  is  necessary  in  order  to  be 
able  to  choose  among  these  various  proce- 
dures. Patients  often  use  them  of  their  own 
accord,  in  a  more  or  less  empirical  and  clumsy 
manner,  and  are  surprised  not  to  derive  from 
them  all  the  profit  that  they  expected ;  it  is 
for  us  to  enlighten  and  guide  them. 

In  the  first  place  we  must  prohibit  the  use 
of  irritating  injections.  I  mean  those  that 
contain  salt,  honey  or  glycerine,  mixed  with 
water.  Patients  often  employ  them  excessively. 
Whatever  be  the  form  of  constipation,  atonic  or 
spasmodic,  these  injections  do  harm  if  repeated 
too  often  ;  in  the  latter  case  they  increase  the 
spasm,  and  consequently  the  constipation  ;  in  the 
former  they  speedily  irritate  the  mucous  mem- 
brane and  predispose  to  membranous  colitis. 
They  should  be  used  only  exceptionally  and 
at  long  intervals,  in  order  to  set  the  intestine 
going ;  and  not  even  so  in  cases  where  there 
is  manifest  intestinal  spasm. 

When  a  choice  has  to  be  made  among  the 
forms  of  injection  enumerated  above,  it  is 
first  necessary  to  investigate  and  determine  as 
far  as  possible  if  the  constipation  is  atonic  or 
spasmodic  in  origin.  The  latter  is  commoner  than 
the  former  in  neurasthenics.  It  may  be  recognised 
by  the  following  signs  :  first,  as  has  already  been 


276  NEURASTHENIA. 

mentioned,  by  the  feel  of  the  colon  on  palpation ; 
it  is  diminished  in  volume,  hard  and  contracted 
(colic  cord),  and  can  be  rolled  under  the  hand  ; 
and  secondly,  by  the  appearance  of  the  faeces, 
which  look  like  long  cylinders  passed  through  a 
draw-plate  and  about  as  thick  as  a  pencil,  or  are 
flat  and  ribbon-like,  and  usually  dry,  or  are  often 
divided  into  small  balls  surrounded  by  mucus. 

In  these  cases,  everything  that  irritates  the 
intestine  increases  the  spasm  and  consequently 
the  constipation.  Hence  those  enemata  must 
be  avoided  which  are  of  a  nature  to  bring 
about  this  result ;  such  are  glycerinated  injec- 
tions, cold  injections,  or  copious  irrigations 
administered  under  too  great  pressure  or  in 
too  great  quantity.1  The  only  forms  that  can 
be  of  use  are  the  small  injections  of  oil,  or 
irrigations  with  2,  or  at  most  3,  pints  of  water 
at  95°  to  104°,  administered  very  slowly  and 
under  low  pressure  (10  to  20  inches  at  most). 

The  suppositories  that  are  sometimes  made 
of  soap  shaped  into  a  cone,  sometimes  of 
cacao-butter  (45  to  60  grains)  with  which  is 
incorporated  glycerine  (12  to  24  minims)  or 
castor  oil,  or  ovules  of  solidified  glycerine  or 
honey,  may  be  useful  especially  in  the  atonic 
form.  They  induce  contractions  of  the  intestine 
not  only  at  the  end  of  the  rectum,  but  along  the 

i  Mathieu  et  J.  Ch.  Roux,  Les  abus  du  lavage  de  Vintestin.     Maladies 
de  I'appareil  digestif.    O.  Doin,  Paris,  1904. 


DIET.  277 

whole  extent  of  the  colon.  In  the  spasmodic 
form,  on  the  other  hand,  they  are  usually  without 
effect,  or  they  may  increase  the  trouble  instead 
of  lessening  it ;  their  use  must  then  be  avoided. 

If  the  procedures  that  we  have  just  passed 
in  review  do  not  suffice  to  induce  regular  stools 
when  used  with  method  and,  especially  in  the 
case  of  the  later  ones,  with  discretion,  it  will  be 
necessary  to  have  recourse  to  laxatives,  though 
with  regret.  In  the  case  of  those  sufferers  from 
constipation  whose  gastric  digestion  is  good, 
we  may  try  the  effect  of  diet  before  using 
drugs  in  the  strict  sense  of  the  word ;  whole- 
meal bread,  which  contains  part  of  the  husk, 
or  even  bran-bread,  which  contains  the  whole 
of  the  husk,  green  vegetables,  fruit  raw  or 
cooked,  honey,  and  coffee  with  milk,  facilitate 
the  stools.  So  do  fatty  foods  in  the  form  of 
bacon  or  butter  (von  Noorden).  But  with  neur- 
asthenics, whose  stomachs  so  often  act  imper- 
fectly, we  cannot  always  use  these  means. 
Kefir,  on  the  other  hand,  which  is  usually  a 
good  food  for  individuals  affected  with  atony, 
also  possesses  laxative  properties  when  it  is 
moderately  fermented. 

As  to  drugs,  we  must  first  make  a  choice 
among  those  that  may  legitimately  be  prescribed, 
and  then  advise  the  use  of  the  selected  medicine 
under  certain  conditions  which  will  be  stated. 

Among  the  laxatives  there  are  some  that  must 


278  NEURASTHENIA. 

be  eliminated ;  these  are  the  saline  aperients — 
sulphate  of  soda,  sulphate  of  magnesia,  citrate  of 
magnesia,  "  purgative  lemonades,"  and  natural 
aperient  waters.  These  have  the  disadvantage 
of  keeping  up  the  tendency  to  constipation, 
their  first  effect  being  followed  by  one  in  a 
contrary  direction.  The  use  of  them  might,  at 
most,  be  permitted  at  long  intervals,  as  occasional 
purgatives.  Exception  must  be  made,  however, 
in  the  case  of  calcined  magnesia,  which  often 
proves  a  useful  laxative  in  doses  of  a  teaspoonf ul, 
not  heaped  up,  taken  before  a  meal,  or  combined 
with  sublimed  and  "  washed  "  sulphur  and 
powdered  sugar,  a  mixture  of  which  the 
same  dose,  a  teaspoonful,  is  to  be  given  in  a 
little  water  at  bedtime. 

The  laxative  to  be  used  first  is  that  which  was 
lately  recommended  by  Trousseau,  following 
Bretonneau,  viz.,  belladonna.  It  should  be  made 
into  pills  each  containing  £  grain  of  the  extract  and 
an  equal  quantity  of  the  powder,  and  one,  two,  or 
even  three  of  these  pills  are  to  be  taken  fasting 
in  the  morning.  Belladonna  is  very  useful  in 
the  spasmodic  constipation  of  neurasthenics. 

If  the  belladonna  alone  is  insufficient,  podo- 
phyllin  may  be  combined  with  it,  as  follows  : — 

% 

Podophylli  Res. 
Ext.  Belladonnas   aa  gr.  "fff 
for  20  pills. 


DIET.  279 

One,  two,  or  even  three  to  be  taken,  either  at 
bed  time  or  in  the  morning  before  breakfast. 

Castor  oil  in  a  dose  of  one  or  two  tea- 
spoonfuls,  taken  simply  in  a  little  coffee  or 
orange- juice,  or  in  capsules,  is  also  a  good  laxa- 
tive, but  the  stomach  has  to  be  reckoned  with ;  it 
does  not  always  tolerate  the  gelatinous  capsules 
in  which  the  drug  is  enclosed,  or  the  oil  itself. 

Compound  powders  (I  am  enumerating  the 
laxatives  in  the  order  of  their  utility)  with  a 
basis  of  senna,  sulphur,  or  fennel  and  especi- 
ally compound  liquorice  powder,  of  which  the 
majority  of  the  others  are  only  imitations,  are  also 
useful.  They  are  given  in  a  dose  of  one  or  two 
teaspoonf uls  in  a  little  sweetened  water,  either 
at  bed  time  or  in  the  morning  before  breakfast. 

Euonymin  in  pills  of  one  grain  combined  with 
J  grain  of  extract  of  hyoscyamus,  powdered 
rhubarb  in  doses  of  7  to  15  grains,  taken  either 
naturally  or  in  cachets,  and  cascarine,  in  one 
grain  pills,  are  also  good  to  fall  back  on. 

Aloes  and  the  greater  number  of  drastic 
purgatives,  such  as  scammony  and  jalap,  are  not 
so  good  to  use.  They  are  too  irritating  to  the 
intestine,  and  may  increase  the  spasm.  Hence 
they  must  only  be  prescribed  very  intermittently 
and  exceptionally,  in  the  form,  for  example,  of 
the  pills  given  in  the  Codex  under  the  names  of 
Bontuis'  and  Anderson's  pills.1  A  very  sedative 

1  Both  of  these  contain  aloes  and  gamboge. — Trans. 


280  NEURASTHENIA. 

and  often  efficient  laxative  that  may  be  employed 
with  advantage,  is  decoction  of  the  bark  of 
black  alder  (Rhamnus  Frangula).  A  decoction 
is  made  of  30  to  60  grains  of  this  bark,  and 
when  it  has  cooled  it  is  left  to  macerate 
for  12  hours ;  it  is  administered  at  bed  time. 

In  treating  the  constipation  of  neurasthenics, 
there  are  certain  rules  that  must  not  be  lost 
sight  of : 

1.  First,     that     on     which    I    have    already 
insisted:  recourse  must  not  be  had  to  laxatives 
till  the  methods  of  simple  hygiene  have  been  tried 
with   regularity  and   sufficient   persistence    and 
have  shown  themselves  ineffectual. 

2.  Laxatives  must  not  be  used  daily,  except 
those    which,    like   belladonna    and    infusion   of 
rhamnus   frangula,   are    relatively   sedative   and 
promote  the  regularity   of    the   stools    after    a 
prolonged  use.     These  may  be  administered  for 
8,  12,   or    15    consecutive  days,   with   the   risk, 
however,  of  finding  at  the  end  of  these  periods 
that  they  have   become  ineffectual.      As  to  the 
others — podophyllin,    euonymin,     rhubarb,     cas- 
carine,1   Seidlitz   powder — they   are    not    to    be 
allowed  more  than  two  or  three  times  a  week, 
and  if  there  is  need  during  the  interval,  enemata 
should  be   recommended   in  one  of   the    forms 
already  indicated. 

i  Cascarine  Le  Prince — a  preparation  oi  Cascara  Sagrada. — 
Trans. 


DIET.  281 

3.  Finally,  it  is  a  good  thing  to  vary  the 
laxative  employed,  by  having  two  or  three  at 
one's  service  which  are  to  be  used  alternately — 
podophyllin,  rhubarb  and  Seidlitz  powder,  for 
example.  In  this  way  it  is  possible  to  avoid 
becoming  habituated  to  a  drug,  which  would 
necessitate  a  more  regular  administration  or 
stronger  doses. 

Before  closing  this  account  of  the  treatment 
of  neurasthenic  constipation,  a  few  words  must 
be  said  about  the  use  of  tobacco.  It  is  known 
that  smoking  possesses  laxative  properties. 
Trousseau  recommended  it  to  his  patients  with 
constipation,  and  sometimes  he  even  went  so 
far  as  to  advise  women  to  adopt  it,  in  despite  of 
our  French  customs.  It  is  certain  that  the  abuse 
of  tobacco,  and  there  are  very  few  smokers  who 
do  not  abuse  it,  does  harm  in  various  ways, 
especially  to  neurasthenics ;  it  may  derange  the 
appetite,  excite  the  circulation  in  an  injurious 
way,  and  accentuate  the  attacks  of  vertigo  and 
loss  of  memory.  Hence  its  abuse — that  is  to  say, 
its  unregulated  and  unmeasured  use — ought  to 
be  forbidden  ;  it  is  better  for  a  neurasthenic  not 
to  smoke  at  all  than  to  do  so  at  his  pleasure. 
But  a  moderate  use  of  tobacco,  consisting  in 
smoking  a  good  and  small  cigar,  or  two  or  three 
cigarettes,  after  lunch  and  dinner,  does  more 
good  than  harm.  The  habit,  when  kept  within 
these  limits,  promotes  the  action  of  the  intestines. 


282  NEURASTHENIA. 

Moreover  it  has  another  use;  it  causes  the 
patient  to  consent  more  readily  to  the  half-hour's 
rest  in  a  semi-recumbent  position  that  we  have 
seen  to  be  so  often  necessary  to  the  regulation 
of  the  digestion.  Men  who  smoke  are  usually 
more  tractable  on  this  point  than  women,  who 
do  not  smoke.  We  should  let  our  patients 
smoke,  then,  unless  in  exceptional  circumstances, 
but  should  not  permit  them  to  do  so  fasting, 
or  before  lunch,  or  in  the  interval  of  meals 
after  the  gastric  digestion  is  over.  The  most 
we  should  allow  to  inveterate  smokers  is  one 
cigarette  after  breakfast  if  it  seems  to  us  certain 
"that  it  is  indispensable  to  enable  them  to  go 
"to  stool." 

It  is  not  uncommon  to  meet  with  an  abdominal 
complication  in  neurasthenics,  as  to  the  nature 
and  etiology  of  which  there  seems  to  be  consider- 
able disagreement ;  I  allude  to  that  which  has 
been  minutely  described  by  Frantz  Glenard,  in  a 
series  of  very  remarkable  works,  under  the  name 
of  visceral  ptosis.  "  It  is  a  state  of  sinking  of 
"the  abdominal  organs,  which  are  otherwise 
"  healthy,  below  their  normal  position  and  in  the 
"  direction  of  gravity."1  It  is  more  commonly 
termed  enteroptosis,  although  ptosis  of  the 
intestine  is  usually  only  one  of  its  constituent 
features,  being  often  associated  with  sinking  of 

i  Frantz  Glenard,  Rapport  sur  Us.  ptoses,  presented  to  the  Societe  de 
medecine  dt  Paris,  14  May,  1903.    Alcan. 


DIET.  283 

other  organs — gastroptosis,  nephroptosis,  hepato- 
ptosis,  and  even  splenoptosis.  This  is  because 
the  ptosis  of  the  stomach,  kidney,  liver  and  spleen 
are  supposed  to  be  subordinated,  as  in  a  hierarchy, 
to  the  ptosis  of  the  intestine. 

Now  the  intestinal  ptosis,  in  Glenard's  view, 
has  two  causes :  it  is  due  either  to  traumatism, 
especially  in  women  who  are  predisposed  to  it  by 
their  organisation  itself,  by  the  use  of  corsets, 
and  by  maternity  ;  or  to  gastric  atony  occurring 
as  a  symptom  of  certain  affections  of  the  liver. 
"  The  symptomatology  of  the  ptoses,"  he  says, 
"  including  mobile  kidney,  mobile  liver,  mobile 
"  spleen,  and  a  number  of  complaints  attributed 
"to  the  stomach  or  the  intestine  or  to  nervous 
"  conditions,  is  essentially  connected  with  the 
"  digestion.  The  neuropathic  state  which  in 
"  most  cases  disguises  this  group  of  symptoms 
"  and  obscures  its  features,  is  in  its  turn  a  con- 
"  sequence  and  not  a  cause  of  this  affection  of 
"  the  digestion." 

I  could  not  absolutely  contradict  Glenard's 
opinion  on  this  point.  I  admit  readily  that  gastric 
dyspepsia,  whether  secondary  to  an  affection  of 
the  liver  or  not,  and  also  enteroptosis  due  to 
purely  mechanical  causes,  are  able  to  bring  on 
neurasthenic  symptoms  secondarily.  But  I  can- 
not accept  the  position  that  in  the  cases  in  which 
ptosis  is  found  clinically  to  be  associated  with 
neurasthenia,  the  latter  is  invariably  to  be 


284  NEURASTHENIA. 

considered  as  a  consequence  of  the  former.  In 
this  respect  I  share  entirely  the  view  formulated 
by  Bouveret  in  his  work,  which  remains  the  classic 
treatise  on  neurasthenia :  "  It  is  certain  that 
"  some  true  neurasthenics  show  signs  of  en- 
"  teroptosis.  They  have  grown  very  thin,  and 
"this  thinness  is  due  to  the  intensity  and  the 
"  long  duration  of  the  disorders  of  digestion  from 
"which  they  suffer.  In  these  patients  entero- 
"  ptosis,  like  dilatation  of  the  stomach,  is  not  the 
"cause  of  the  neurosis,  but  it  is  rather  the  result, 
"  early  or  late,  of  the  gastro-intestinal  atony, 
"  which  itself  proceeds  from  the  nervous  exhaus- 
"  tion  in  the  same  way  as  all  the  other  symptoms 
"  of  that  morbid  condition.  Such  is  the  place 
"  which  it  is  right  to  assign  to  en  teroptosis  in  the 
"  pathology  of  neurasthenia."1 

Even  if  Glenard  and  I  came  to  an  agreement 
on  the  general  theoretical  question,  which  does 
not  seem  to  me  to  be  impossible,  I  am  not  sure 
that  the  respective  statistics  which  we  should 
collect  with  the  object  of  determining  the  relative 
proportion  of  primitive  and  secondary  entero- 
ptosis,  would  give  concordant  results.  The  differ- 
ence in  the  figures  shown  by  these  statistics, 
which  it  would  be  easy  to  draw  up  according  to 

i  Bouveret,  La  Neurasthenic,  Paris,  1891,  2e  6dit.,  J.  B.  Bailliere. 

[A  third  view  of  the  connection  between  neurasthenia  and 
enteroptosis,  differing  both  from  that  of  Glenard  and  from  that  of 
Bouveret,  may  be  found  in  Brit.  Med.  Journ.  1906,  Vol.  I.,  p.  494. — 
Tr*ns.\ 


DIET.  285 

the  same  plan  of  observation,  would  depend  less 
on  the  easily  rectified  divergence  of  our  points 
of  view  than  on  the  different  conditions  under 
which  our  observations  would  be  made.1 

However  this  be,  enteroptosis  is  often  observed 
in  neurasthenics,  sometimes  in  men,  but  much 
oftener  in  women,  who  are  especially  predisposed 
to  abdominal  displacements  by  the  use  of  corsets 
and  above  all  by  pregnancies.  In  these  cases  the 
abdomen  appears  wasted,  and  its  walls  are 
flaccid  and  seem  too  large  for  their  contents  ; 
when  the  patient  is  sitting  or  standing,  the 
hypogastric  region  projects  abnormally ;  when 
lying  down,  on  the  other  hand,  it  is  the  lumbar 
regions  that  bulge ;  it  is  very  manifest  that  the 
girdle  formed  by  the  abdominal  parietes  does  not 
come  in  contact  with  the  viscera  so  as  to  hold 
them  in  place.  Peristaltic  movements  of  the 
distended  stomach  are  seen  at  the  level  of  the 
umbilicus,  and  even  lower ;  the  intestine  is 
diminished  in  calibre  and  retracted.  Palpation 
shows  the  ccecal  sausage  in  the  right  iliac  fossa, 
the  colic  cord  along  the  course  of  the  transverse 
colon,  and  the  sigmoidal  cord  in  the  left  iliac 
fossa.  These  terms  are  due  to  Glenard,  from 
whom  the  following  description  of  these  con- 
ditions of  the  large  intestines  are  borrowed. 

The  ccecal  sausage  is  sometimes  visible  to  the 

i  Presumably  this  means  that  their  patients  are  drawn  from 
different  classes. — Trans. 


286  NEURASTHENIA. 

naked  eye.  It  is  deviated  so  as  to  be  internal  to 
the  usual  position  of  the  caecum.  Its  diameter  is 
not  more  than  £  inch  to  2  inches.  Its  length  is 
perceptible  for  a  distance  equal  to  the  breadth  of 
four  or  five  fingers.  On  pressure  it  usually  gives 
a  feeling  of  elastic  resistance,  showing  that  its 
contents  are  chiefly  gaseous,  and  in  this  case  the 
tumour  is  resonant  to  percussion ;  or  it  has  a 
doughy,  or  even  hard,  consistence,  indicating  that 
it  is  filled  by  solid  matter.  When  it  is  reduced 
to  the  diameter  of  a  finger,  it  may  have  the 
consistence  of  a  bundle  of  muscular  fibres  in 
relaxation.  The  caecal  sausage  can  be  moved 
from  side  to  side,  but  not  upwards. 

The  colic  cord  consists  of  the  prolapsed  trans- 
verse colon.  It  is  best  seen  in  thin  subjects.  The 
highest  point  at  which  it  is  found  is  an  inch  above 
the  umbilicus,  the  lowest  2  inches  above  the 
pubes.  It  is  most  often  seen  in  the  mesial  line 
only ;  fairly  frequently,  however,  it  is  not  mesial 
but  lateral,  either  to  the  right  or  to  the  left,  and 
in  this  case  it  is  always  in  the  umbilical  region. 
The  cord  is  usually  of  the  thickness  of  a  finger, 
but  it  may  be  thicker,  in  which  case  it  is  more 
prolapsed.  In  the  former  case  it  is  soft  in  con- 
sistence, in  the  latter  it  can  be  felt  loaded  with 
scybala.  Light  but  continuous  pressure  on  the 
cord  elicits  a  fine  gaseous  crepitation,  and  pro- 
duces contraction,  which  is  shown  by  hardening 
and  constriction  of  the  intestine. 


DIET.  287 

The  sigmoidal  cord  lies  in  the  left  iliac  fossa,  in 
the  part  near  Poupart's  ligament,  parallel  to  the 
fold  of  the  groin  and  at  a  distance  of  two  or 
three  finger-breadths  from  it.  It  is  as  thick  as  a 
goose-quill,  can  be  seen  for  a  length  of  3  to  4 
inches,  and  sometimes  its  hardness  may  be 
compared  to  that  of  a  goose-quill;  on  the  other 
hand  it  may  be  thicker  and  show  itself  as  a 
knotty  cylinder,  loaded  with  scybala.  It  is  not 
painful  on  pressure,  but  it  sometimes  happens, 
as  in  the  case  of  the  caecum,  that  pressure 
may  induce  nervous  symptoms  such  as  might  be 
ascribed  to  the  ovary  if  one  had  not  the 
sigmoidal  cord  under  one's  fingers. 

Hepatoptosis  is  often  associated  with  entero- 
ptosis  ;  in  this  case  the  lower  border  of  the  liver 
is  felt  at  a  greater  or  less  distance  below  the 
costal  margin. 

But  it  is  nephroptosis  (mobile  kidney)  that  is 
especially  common  in  those  with  enteroptosis. 
Glenard  distinguishes  two  varieties  of  mobile 
kidney — the  hypochondriac  and  the  lumbar. 
These  can  be  recognised,  according  to  him,  by 
having  recourse  to  a  method  of  exploration  which 
he  has  well  described  in  detail.  In  the  first  stage 
the  hands  are  placed  in  readiness  at  the  base  of 
one  of  the  hypochondriac  regions,  so  that  if  the 
kidney  is  lowered  by  a  deep  inspiratory  movement 
on  the  part  of  the  patient,  that  is  to  say,  if  it  is 
mobile,  it  necessarily  comes  within  reach  of  the 


288  NEURASTHENIA. 

fingers.  In  the  second  stage  (capture)  the  fingers 
make  an  effort  to  seize  the  kidney.  In  the  third 
stage  (escape)  they  have  seized  it  and  compress 
its  lower  pole  forcibly,  so  as  to  make  it  escape 
with  a  rebound.  The  stage  of  escape  furnishes 
the  pathognomonic  sign  of  mobile  kidney — viz., 
the  special  rebound  at  the  moment  when  its  lower 
pole  escapes  from  the  pressure  of  the  fingers. 
The  hypochondriac  mobile  kidney  can  be  palpated 
during  inspiration  only,  the  lumbar  mobile  kidney 
even  at  the  end  of  expiration. 

Among  the  complex  group  of  disorders  ex- 
hibited by  neurasthenics  with  enteroptosis,  are 
there  any  functional  symptoms  that  can  be 
referred  with  certainty  to  the  latter  condition  ? 
The  question  is  not  so  simple  to  answer  as 
might  appear.  Gastric  atony,  intestinal  atony 
and  intestinal  spasm,  when  acting  alone,  cause 
dyspeptic  troubles  of  such  a  nature  that  it  is 
by  no  means  easy,  in  cases  of  enteroptosis,  to 
disentangle  those  that  are  due  to  the  atony 
or  spasm  from  those  that  are  due  to  the 
enteroptosis  itself.  It  seems  to  me,  however, 
that  neurasthenics  with  enteroptosis  show  cer- 
tain symptoms  that  do  not  exist,  at  any  rate 
to  the  same  degree,  in  those  whose  abdominal 
organs  are  not  prolapsed ;  such  are  the  sen- 
sations which  the  patients  describe  as  weak- 
ness or  disorder  of  the  stomach,  twinges  of  pain 
in  the  stomach,  false  sensations  of  hunger,  feelings 


DIET.  289 

of  emptiness,  aching  across  the  loins,  most  of 
which  figure  among  the  symptoms  connected 
with  the  umbilical  region  in  Glenard's  descrip- 
tion. I  do  not  know  if  the  same  can  be 
said  of  the  insomnia  occurring  especially  be- 
tween two  and  four  o'clock  in  the  morning, 
and  of  the  dyspepsia  without  loss  of  appetite 
which  is  relieved  by  a  diet  of  boiled  eggs  and 
grilled  meat,  by  frequent  meals,  daily  laxatives, 
bicarbonate  of  soda  and  the  dorsal  decubitus, 
both  of  which  symptoms  the  distinguished 
Vichy  physician  attributes  to  enteroptosis.  On 
the  other  hand  I  readily  agree  with  him 
that  enteroptosis,  by  setting  up  a  mechanical 
hindrance  to  the  free  circulation  of  the  con- 
tents of  the  alimentary  canal,  may  cause  the 
attacks  of  painful  colic  which  these  patients 
often  enough  feel,  either  by  day  or  by  night. 
When  enteroptosis  occurs  as  a  complication 
of  neurasthenia,  it  requires  special  treatment. 
The  first  thing  is  to  avoid  the  mechanical 
causes  that  are  of  a  nature  to  increase  the 
ptosis ;  hence  the  patients  must  avoid  all  bands, 
buckles,  and  belts  that  are  liable  to  compress 
the  abdomen  and  push  its  contents  downwards  ; 
women  should  wear  special  corsets,  such  as 
are  readily  made  nowadays,  which  support  the 
waist  without  squeezing  it,  and  leave  the 
abdomen  free.  The  second  indication  is  to  raise 
the  abdominal  viscera,  and  to  keep  them  up.  It 

Neurasthenia.  *  19 


290  NEURASTHENIA. 

is  carried  out  by  means  of  Glenard's  belt.  This 
is  an  elastic  band,  about  6  inches  wide,  suffici- 
ently firm,  even,  and  with  straight  and  parallel 
edges ;  if  desired,  it  may  be  hollowed  over  the 
trochanters  by  turning  up  the  lower  border  in  the 
corresponding  positions  ;  it  is  fastened  at  the 
back  by  three  buckles,  and  is  furnished  with 
perineal  bands.  It  is  applied  to  the  most 
dependant  part  of  the  abdomen,  and  surrounds 
the  pelvis  in  such  a  way  that  the  upper  edge  of 
the  band  reaches  only  one  or  two  finger- 
breadths  above  the  iliac  crests.  It  must  be 
tightened  sufficiently,  and  must  be  constantly 
worn  by  day;  Glenard  advises  that  it  be  some- 
times worn  at  night  also,  when  insomnia  proves 
refractory  to  treatment.  The  belt  may  advan- 
tageously be  furnished,  as  Mathieu  proposes,  with 
a  semilunar  pad,  which  will  compress  and  raise 
up  the  hypogastrium  and  the  iliac  fossae.  Various 
modifications  have  been  made  in  the  details  of 
Glenard's  belt,  and  more  or  less  perfected  bands 
can  be  found  at  the  instrument-makers. 

As  enteroptosis  hampers  the  movements  of 
the  intestinal  contents,  it  is  necessary  to  have 
recourse  to  laxative  medication,  which,  in 
Glenard's  view,  is  one  of  the  fundamental 
indications  of  the  treatment.  He  advises  that 
it  be  carried  out  by  the  daily  administration 
of  a  saline  aperient,  either  in  the  form  of  a 
small  dose  of  some  natural  purgative  water  (as 


DIET.  291 

Hunyadi  Janos,  Villacabras,  or  Rubinat),  •  or 
by  giving  60  grains  of  sulphate  of  soda  with 
45  grains  of  sulphate  of  magnesia  in  half  a 
glass,  of  cold  water  every  morning. 

For  my  part,  I  have  not  found  that  the 
treatment  of  the  constipation  of  neurasthenics 
with  enteroptosis  differs  from  that  of  the  con- 
stipation of  neurasthenics  without  enteroptosis, 
such  as  I  have  already  described.  It  only  requires 
a  more  rigorous,  more  methodic,  and  more  con- 
tinuous application  of  the  measures  already  given. 
I  do  not  share  Glenard's  infatuation  for  saline 
aperients  in  neurasthenics  with  visceral  prolapse, 
and  I  persist  in  considering  their  habitual  use, 
which  I  have  recommended  to  be  avoided  in  simple 
neurasthenic  constipation,  as  equally  injurious  in 
the  case  of  neurasthenics  affected  with  entero- 
ptosis. I  object  to  them  as  keeping  up  the 
tendency  to  constipation,  and  as  rendering  them- 
selves indispensable,  and  I  cannot  advise  the  use 
of  them  except  occasionally,  or  in  cases  in  which 
the  constipation  has  shown  itself  refractory  to 
the  other  measures  on  which  I  laid  stress. 

The  constipation  which  is  so  common  in 
neurasthenia,  as  we  have  seen,  and  often  so 
obstinate,  sometimes  gives  rise  to  a  troublesome 
complication  which  becomes  a  new  source  of 
annoyance  to  the  patient  and  of  mortification  to 
the  doctor ;  I  allude  to  enteritis,  or  rather  to 
muco-membranous  colitis. 


NEURASTHENIA. 

This  complication  is  by  no  means  always  a 
consequence  of  neurasthenia.  It  is  observed  in 
children  as  a  sequel  to  attacks  of  acute  colitis,  and 
its  occurrence  is  promoted  in  women  by  lesions 
of  the  uterine  appendages  and  by  tight  corsets 
which  cause  ptoses,  and  in  people  of  easy  cir- 
cumstances by  the  excessive  use  of  meat  and 
spiced  dishes.  The  neuro-arthritic  temperament 
seems  to  predispose  to  it.  But,  independently 
of  cases  arising  in  these  different  ways,  there  is 
no  doubt  that  muco-membranous  colitis  is  often 
a  more  or  less  distant  sequel  of  the  constipa- 
tion that  is  associated  secondarily  with  the 
different  neurasthenic  states. 

The  common  exciting  cause  is  the  over-use  of 
irritating  injections  or  suppositories,  or,  on  the 
other  hand,  a  neglect  of  the  precautions  required 
by  the  constipation. 

A  patient  who  at  first  suffers  from  the  simple 
constipation  of  neurasthenia,  and  who  is  more 
or  less  solicitous  about  his  constipation,  notices 
after  a  certain  time  that  the  stools,  which 
are  often  divided  up  in  scybala  and  formed  of 
small  hard  balls  like  those  of  sheep,  are  sur- 
rounded by  more  or  less  liquid  or  adherent 
mucus,  resembling  raw  or  boiled  white  of  egg. 
The  mucus  becomes  steadily  more  abundant ; 
after  periods  of  constipation,  the  duration  of 
which  varies  according  to  the  treatment,  there 
comes  a  general  clearance  of  the  intestine ;  and 


DIET.  293 

if  the  motions  are  exammed,  they  are  found  to 
consist  sometimes  of  faecal  matter  mixed  with 
mucus,  sometimes  exclusively  or  almost  exclu- 
sively of  mucus.  This  has  the  aspect  of  glutinous 
masses,  resembling  raw  white  of  egg,  or  rather 
frog's  spawn ;  mixed  with  it  are  particles  of 
solid  mucus,  having  rather  the  appearance  of  fat, 
or  boiled  white  of  egg,  or  curdled  milk.  The 
quantity  of  these  glutinous  mucosities  is  very 
variable ;  the  patients  pass  at  first  about  as 
much  as  a  teaspoonful,  then  a  wineglassful,  then 
a  tumblerful.  As  a  rule  it  is  not  till  later  that 
"skins"  and  false  membranes  appear.  These 
more  or  less  resemble  newly  formed  fibrinous 
membranes ;  they  vary  much  in  dimensions, 
sometimes  not  exceeding  J  or  £  square  inch, 
and  sometimes  forming  a  sort  of  small  sheet  cut 
at  the  edges,  and  about  an  inch  wide  by  3,  4  or 
more  inches  long  ;  they  may  then  resemble  a  piece 
of  tape  or  a  taenia.  At  other  times  they  have  a 
tubular  form,  and  may  then  attain  a  length  of  4, 
6,  or  even  10  inches.  From  the  already  old  re- 
searches of  Laboulbene,  which  have  been  con- 
firmed and  completed  by  the  more  recent  investi- 
gations of  Edwards,  Nothnagel,  Kitagawa  and 
Swen  Akerlund,  Schmidt,  and  Krysinski,  it  is 
known  that  these  false  membranes  are  composed 
of  strata  of  solidified  mucus,  without  a  trace  of 
fibrin,  and  with  cells  of  different  kinds  in  its 
interstices — epithelial  cells  from  the  intestine, 


294  NEURASTHENIA. 

leucocytes,  and  red  corpuscles — and  also  an 
abundance  of  different  micro-organisms. 

Muco-membranous  colitis  is  not  a  negligible 
complication  in  the  case  of  neurasthenics.  It 
brings  on  paroxysmal  crises  of  pain  that  render  the 
existence  of  the  patients  particularly  distressing. 
These  crises  are  at  first  separated  by  considerable 
intervals,  but  they  may  become  more  and  more 
frequent  till  there  is  no  day  on  which  the  patients 
do  not  experience  them.  They  occur  most  often 
several  hours  after  a  meal,  or  about  the  middle 
of  the  night,  and  manifest  themselves  by  colic, 
by  sharp  sensations  of  burning,  or  by  cramp,  some- 
times just  above  or  below  the  umbilicus,  in  the  re- 
gion corresponding  to  the  transverse  colon,  some- 
times in  that  of  the  sigmoid  flexure,  more  rarely  in 
that  of  the  ascending  colon.  This  pain  is  often 
severe  enough  to  recall  the  pains  of  labour  or  those 
of  hepatic  colic.  It  sometimes  radiates  to  the  back, 
the  loins,  or  to  the  bladder,  where  it  causes  vesical 
tenesmus.  It  may  be  accompanied  by  a  feeling 
of  faintness.  A  crisis  is  usually  the  prelude 
of  an  intestinal  flux,  in  the  course  of  which  the 
patient  passes  a  more  or  less  considerable,  some- 
times very  considerable,  quantity  of  mucus  and 
false  membranes. 

In  the  intervals  of  the  crises  of  pain,  the  bowel 
often  remains  tender,  especially  in  the  region  of 
the  left  iliac  fossa,  but  sometimes  also  in  that  of 
the  caecum.  Palpation  usually  shows  the  caecum 


DIET.  295 

to  be  more  or  less  distended  by  gas,  and  sensitive 
to  pressure,  whereas  the  transverse  colon  and 
the  descending  colon,  which  are  more  or  less 
painful,  are  contracted  and  in  a  state  of  spasm, 
and  can  be  rolled  under  the  fingers.  When  the 
caecum  is  painful,  the  sensation  is  sometimes 
propagated  along  the  inner  surface  of  the  thigh. 

Another  consequence  of  membranous  colitis  is 
the  appearance  of  symptoms  of  auto-intoxication 
under  the  influence  of  intestinal  fermentations 
promoted  by  the  colitis,  or  even  of  symptoms 
of  infection  from  the  multiplication  of  micro- 
organisms. It  was  at  one  time  hoped  that  analysis 
of  the  urine  would  confirm  the  information  afforded 
by  clinical  examination.  It  is  well  known  that 
intestinal  fermentations  give  rise  to  three  kinds 
of  toxic  products :  the  fermentation  of  carbohy- 
drates produces  fatty  acids  (butyric,  caproic,  and 
valerianic),  and  that  of  proteids  produces  pto- 
maines and  aromatic  substances  (indol,  skatol, 
and  phenol)  which  combine  with  sulphuric  acid  in 
their  passage  through  the  liver,  forming  the 
ethereal  sulphates.  The  ideal  would  be  to  make 
a  quantitative  estimate  of  these  different  products ; 
in  practice  this  is  not  possible,  but  at  least  we 
can  estimate  the  ethereal  sulphates  in  the  urine, 
and  from  the  amount  of  them  we  can,  to  a  certain 
extent,  judge  the  degree  of  intestinal  putrefaction. 
The  matter  would  be  simple  if  we  knew  the 
normal  average  amount  of  these  sulphates,  but 


296  NEURASTHENIA. 

chemists  are  not  agreed  about  this  quantity ; 
moreover  it  varies  so  much  according  to  the 
composition  of  the  diet  that  we  must  give  up 
trying  to  establish  a  valid  average.  The  method 
of  coefficients  is  also  tainted  with  error.  This 
method  consists  of  taking  into  consideration  not 
the  absolute  weight  of  a  substance  in  the  urine, 
but  the  ratio  of  its  weight  to  that  of  another 
substance,  the  variations  of  which  in  the  normal 
condition  are  supposed  to  be  parallel  to  those  of 
the  first.  The  coefficient  most  easily  used  is 
that  of  Baumann.  It  expresses  the  relation 
between  the  sulphuric  acid  combined  into  inor- 
ganic sulphates  and  that  combined  into  ethereal 
sulphates,  and  is  as  follows : 


Sulphuric  acid  in  the  form  of  ethereal  sulphates  _        1 
Sulphuric  acid  in  the  form  of  inorganic  sulphates  10 


This  would  be  very  useful  if  it  were  not  that 
changes  in  food  cause  the  amount  of  the  inorganic 
sulphates  to  vary  at  the  same  time ;  so  that  the 
coefficient  may  be  altered  by  other  influences 
than  those  of  intestinal  fermentations.  We  must 
not  attach  too  much  importance  to  the  results  of 
chemical  investigations  so  long  as  they  have  not 
acquired  sufficient  exactitude ;  we  should  be 
exposed  to  committing  the  worst  of  errors — that 
which  hides  itself  under  the  apparent  precision  of 
figures.  Baumann's  coefficient  should  be  re- 
membered, however,  so  that  on  occasion  we  may 


DIET.  297 

make  use  of  it  with  such  degree  of  confidence  as 
it  deserves.1 

Some  patients  are  constantly  in  a  half  febrile 
state.  They  are  always  complaining  of  cold, 
especially  in  the  extremities,  a  feeling  of  cold 
that  alternates  with  rushes  of  heat.  One  is 
surprised  to  see  them  covered  with  furs,  even  in 
the  height  of  the  summer.  They  have  anorexia, 
a  coated  tongue,  a  bad  breath,  and  frequently  a 
state  of  nausea.  The  face  is  yellowish  and  thin. 
At  such  times  neurasthenics  complain  of  headache, 
attacks  of  vertigo,  and  insomnia,  even  more  than 
ordinarily.  The  stools  in  these  circumstances 
contain  not  mucus  only,  but  soft  and  foetid  matter 
mingled  with  it.  In  short,  there  are  all  the  signs 
that  reveal  intestinal  auto-intoxication. 

This  is  not  the  place  to  give  a  full  history  of 
muco-membranous  enteritis,  for  it  is  far  from 
being  a  manifestation  of  neurasthenia  exclusively. 
It  is  in  treatises  on  affections  of  the  digestive 
passage  that  a  suitably  detailed  study  will  be 
found2;  but  as  neurasthenia  predisposes  to  it, 
promotes  its  development,  and  is  often  compli- 
cated by  it,  it  was  necessary  to  indicate  the  new 
features  that  it  adds  to  the  clinical  picture  of 
neurasthenia,  when  it  is  associated  with  it.  There 

1  On  this  subject  see  an  excellent  review  by  Gaston  Lyon,  in 
Gaz.  des  Hopitaux,  14  May,   1904. 

2  See  especially  A.  Mathieu,  Traite  des  maladies  de  Vestomac  et  de 
I'intestin,   Paris,   O.  Doin,  1901,  and   the  recent  book   by   Combe 
(Lausanne). 


298  NEURASTHENIA. 

remain  to  be  mentioned  the  new  indications  that 
it  furnishes  in  the  matter  of  treatment. 

As  the  muco-membranous  enteritis  of  neuras- 
thenics results  from  constipation,  whether  associ- 
ated with  enteroptosis  or  not,  the  means  of 
preventing  it,  and  of  mitigating  it  when  it  has 
occurred,  consist  above  all  things  in  dealing  with 
the  enteroptosis  and  constipation.  I  need  not 
return  to  the  methods  of  doing  this  that  are  at 
our  disposal.  What  I  must  say  here  is  that  we 
must  have  recourse  to  them  with  all  the  more 
assiduity,  the  more  danger  there  is  of  the  occur- 
rence of  membranous  colitis ;  this  may  be 
estimated  by  examining  the  motions  from  time  to 
time,  or  by  having  them  examined.  We  must 
redouble  our  cares  if  we  find  those  glutinous 
mucosities  that  indicate  the  beginning  of  the 
affection. 

When  the  complaint  is  established,  it  is  im- 
portant to  prevent  or  do  away  with  the  complica- 
tions of  auto-intoxication  or  intestinal  infection 
which  it  so  often  occasions.  To  this  end  the 
intestine  must  be  rendered  as  aseptic  as  possible. 
Three  means — of  unequal  value — are  at  our 
disposal : 

1.  Intestinal  antiseptics,  and  purgatives. 

2.  Enemata,  antiseptic  or  not. 

3.  Diet. 

Intestinal  antiseptics  have  lost  much  of  their 
prestige.  Naphthol,  benzonaphthol,  and  salol — 


DIET.  299 

the  first  two  at  Least — irritate  the  stomach  and 
have  no  marked  action  on  the  intestine.  Betol, 
which  is  a  compound  of  salicylic  acid  and  naphthol, 
has  not  the  same  disadvantages,  and  has  some- 
times seemed  to  me  to  be  really  useful ;  it  is  to  be 
prescribed  in  cachets  of  7  to  14  grains  each,  to 
be  taken  twice  a  day,  half  an  hour  or  an  hour 
after  each  meal.  I  may  say  as  much  of  salacetol, 
which  is  recommended  by  Bourget  (Lausanne) ; 
it  has  appeared  to  me  to  be  a  good  antiseptic,  but 
it  also  has  the  defect  of  irritating  the  stomach. 
Hence  it  cannot  be  given  continuously.  But  in 
doses  of  7  to  10  grains,  in  cachet,  at  bedtime, 
every  fourth  or  fifth  day,  it  is  of  real  service. 

Purgatives  are  the  best  medicinal  antiseptics 
for  patients  who  have  membranous  enteritis. 
The  bacteriological  researches  of  Gilbert  and 
Dominici  have  demonstrated  with  exactitude 
what  had  already  been  established  by  clinical 
observation.  Hence  it  will  be  good  to  give  a 
small  dose  of  a  saline  purgative  from  time  to 
time,  say  once  or  twice  a  week ;  300  grains  of 
sulphate  of  soda  or  magnesia,  a  tumblerful  of 
Montmirail,  Carabana,  or  Hunyadi  Janos  water, 
or  half  a  tumbler  of  Rubinat.  Castor  oil,  in 
ounce  doses,  will  be  of  similar  service,  and  so 
will  calomel.  It  will  be  found  very  good  to 
combine  these  two  drugs  in  the  manner  once 
indicated  by  Bretonneau,  which  consists  in  giving 
2  grains  of  calomel  in  the  evening  at  bed-time, 


300  NEURASTHENIA. 

and  three-quarters  of  an  ounce,  or  an  ounce,  of 
castor  oil  in  the  morning.  This  purgation  may 
be  repeated  every  ten,  twelve,  or  fifteen  days  if 
needed.  It  must  be  remembered,  however,  that 
it  is  inapplicable  in  the  case  of  certain  patients, 
because  of  the  colic  which  calomel  sometimes 
causes  when  taken  under  the  conditions  which  I 
have  just  mentioned. 

Whatever  be  the  utility  of  purgatives  in  muco- 
membranous  enteritis,  we  must  not  forget  that 
they  must  be  given  at  intervals ;  if  given  too 
frequently  or  for  too  long  a  time,  they  irritate  the 
intestine  and  increase  the  pains.  The  patient 
must  be  watched  attentively  so  that  they  may  be 
prescribed  opportunely,  and  the  use  of  them 
suspended  when  they  cease  to  be  of  benefit. 

Washing  out  the  intestine  is  also  a  good  means 
of  remedying  the  complication  of  infection.  It 
is  to  be  ordered  in  the  same  form  and  with  the 
same  precautions  that  were  indicated  in  connec- 
tion with  the  treatment  of  simple  constipation. 
The  suggestion  has  been  made  that  antiseptics 
or  other  modifying  substances  should  be  mixed 
with  the  fluid  used  for  the  washing ;  their  utility 
has  not  been  demonstrated  so  clearly  as  their 
disadvantages.  Ichthyol,  however,  which  has 
been  recommended  by  Bourget,  Blondel,  and 
Mathieu,  may  be  employed  with  benefit.  Mathieu 
advises  that  1  to  3  tablespoonfuls  of  a  20  per 
cent,  solution  of  neutral  sulphichthyolate  of 


DIET.  301 

ammonium  be  mixed  with  each  quart  of  boiled 
water. 

Certain  watering  places,  as  Chatel-Guyon, 
Plombieres,  and  Marienbad,  are  of  service  in 
muco-membranous  enteritis ;  their  utility  is  due 
to  the  fact  that  they  contribute  to  the  regulating 
of  the  bowels,  as  in  the  case  of  Chatel-Guyon 
and  Marienbad,  or  to  the  methods  of  irrigating 
and  cleansing  the  intestines  that  are  in  current 
use,  as  at  Plombieres  for  example. 

Diet  is  of  capital  importance  in  membranous 
colitis.  At  the  beginning,  when  constipation  is 
the  dominating  symptom,  and  when  cure  of  the 
constipation  is  enough  to  cause  the  disappear- 
ance of  the  glutinous  mucosities  that  the  too 
infrequent  stools  contain,  the  use  of  green 
vegetables  cooked,  or  of  fruits  cooked  or  raw, 
may  be  advised  when  it  has  been  ascertained 
that  the  stomach  is  able  to  tolerate  them ;  grapes 
and  oranges  may  be  tried,  taken  in  the  morning 
before  breakfast.  But  it  must  not  be  forgotten 
that  we  are  now  considering  patients  affected 
with  neurasthenia,  and  therefore  almost  always 
with  gastric  dyspepsia,  so  that  they  do  not 
always  support  well  the  foods  of  which  I  have 
just  spoken.  One  of  the  great  difficulties  in 
treating  gastro-intestinal  disorders  in  neuras- 
thenia depends  on  the  varying  complexity  of 
those  disorders,  and  on  the  consequent  multi- 
plicity of  the  therapeutical  indications.  Hence 


302  NEURASTHENIA. 

we  cannot  fix  on  a  simple  and  special  diet; 
general  rules  determined  beforehand  are  subject 
to  many  modifications  according  to  the  nature  of 
the  cases,  and  here,  as  everywhere,  the  physician 
must  have  observation  and  tact  in  order  to  hit 
upon  the  treatment  that  is  best  adapted  to  the 
situation. 

What  I  have  just  said  of  the  diet  directed 
against  constipation,  applies  also  to  the  diet 
directed  against  intestinal  infection.  To  consider 
this  last  only,  the  regimen  must  be  combined  in 
such  a  way  as  to  promote  fermentations  and 
the  reproduction  of  microbes  as  little  as  possible. 
From  this  point  of  view  the  best  foods  are  milk, 
kefir,  and  starchy  articles.  Milk  has  an  anti- 
fermenting  action  which  is  well  known  and  has 
been  shown  more  clearly  by  the  works  of  Poehl, 
Biernacki,  Winternitz,  Gilbert,  and  Dominici. 
But  neurasthenics  are  not  always  willing  to 
take  it,  as  they  say  that  it  does  not  suit  their 
stomachs. 

Kefir  has  an  action  similar  to  that  of  milk,  and 
should  be  preferred  to  milk  if  it  can  be  procured 
and  if  it  is  sufficiently  fresh;  patients  soon 
become  used  to  it  as  a  rule,  and,  apart  from 
exceptional  cases,  support  it  exceedingly  well. 

But  a  rigid  diet  of  milk  or  kefir  is  needed  only 
when  there  is  present  an  acute  stage  of  muco- 
membranous  enteritis,  with  severe  pain  and  loss 
of  appetite. 


DIET.  303 

i 

It  has  been  established  by  a  number  of  experi- 
ments, especially  those  of  Hoppe  Seyler,  Krauss, 
and  Combe  (Lausanne),  that  farinaceous  food 
diminishes  intestinal  putrefaction  l ;  moreover  it 
is  said  to  promote  the  digestion  of  proteids 
(Riibner,  Krauss,  Muncke,  Wicke  and  Weiske). 
On  the  strength  of  these  facts,  farinaceous  foods 
have  been  made  the  basis  of  the  diet  of  patients 
with  auto-intoxication  of  intestinal  origin. 
Combe, 2  following  Grawitz,  Senator,  Rosenheim 
and  some  others,  has  laid  down  the  rules  of  this 
diet.  It  is  composed  of  milk,  malted  starches, 
potatoes,  such  doughy  substances  as  vermicelli, 
macaroni,  and  other  pastes  of  similar  character, 
rice,  semolina,  tapioca,  sago,  arrowroot.  The 
mode  of  preparation  of  these  foods  is  of  great 
importance.  The  malted  starches  are  made  into 
soups  by  cooking  them  in  water  for  about  half  an 
hour,  and  afterwards  adding,  if  desired,  a  quarter 
or  half  the  amount  of  milk.  Potatoes  are  baked, 
or  boiled  and  made  into  a  puree  with  the  addition 
of  butter  after  cooking.  The  doughy  foods  or 
pastes  are  cooked  in  salt  water  for  twenty  to 
forty  minutes,  and  a  little  fresh  butter  is  added 
at  the  moment  of  serving.  Rice,  semolina, 
tapioca  and  arrowroot  will  serve  to  make  soups 
or  puddings,  with  the  addition  of  milk,  sugar,  and 
yolk  of  egg. 

1  Gaston   Lyon,  Prophylaxie  et  traitement    des    auto-intoxications 
(Torigine  intestinal  (Gaz.  des  hopitaux,  No.  55,  1904). 

2  Combe,  Arch,  de  Medec.  des  enfants,  Jan.  and  Feb.,  1904. 


304  NEURASTHENIA. 

Combe  recommends  that  frequent  meals  be 
taken,  and  that  solids  and  liquids  should  be  taken 
separately  and  alternately.  Thus  six  meals  a  day 
may  be  advised :  three  solid  meals,  at  7.30  a.m., 
12.30  p.m.,  and  7.30  p.m.,  and  three  liquid  meals, 
at  10  a.m.,  3.30  p.m.,  and  5  p.m. 

Finally,  if  nitrogenous  food  other  than  milk  or 
eggs  is  taken,  that  is  to  say,  if  meat  is  taken  as 
well  as  starchy  substances,  the  patient  must  be 
careful  to  take  about  five  times  as  much  carbo- 
hydrates as  proteids. 

This  diet,  which  succeeds  well  in  the  enteritis 
of  children  and  adults,  gives  good  results  also  in 
cases  of  muco-membranous  enteritis  accompanied 
by  putrefactive  fermentations.  But  in  adminis- 
tering it  to  neurasthenics,  one  often  enough 
stumbles  against  objections  founded  on  the 
difficulty  that  the  stomach  finds  in  digesting 
starchy  matters ;  the  patients  often  complain  that 
foods  of  this  kind  "blow  them  out "  or  "suffocate 
them,"  and  one  is  obliged  to  compromise  with 
them.  On  the  other  hand,  if  the  stomach  is  atonic, 
as  is  frequently  the  case,  digestion  takes  place 
slowly,  and  fairly  long  intervals  must  be  left 
between  meals,  which  excludes  the  possibility  of 
frequent  meals. 

The  following  is  the  scheme  I  usually  formulate 
for  the  diet  of  neurasthenics  who  are  affected 
with  membranous  colitis  accompanied  by  symp- 
toms of  intestinal  fermentation. 


DIET.  305 

1.  In  cases   where  the   coated   state  of  the 
tongue  is  very   marked,  where  there  is  loss  of 
appetite,  distension  of  the  abdomen,   severe  and 
frequent  attacks  of  pain,  attacks  of  diarrhoea  with 
abundant  false  membranes  and  putrid  stools,  the 
diet  is  to  be  exclusively  of  milk,  which  may  be 
taken   as   the    patient    prefers,   either    in   small 
quantities     frequently     repeated,    or     in    larger 
quantities  at  longer  intervals  ;  or,  better  still,  an 
exclusive   diet  of   kefir   No.  2,  of  which  4  to  6 
glasses    are    given    daily.       Few    patients    can 
tolerate  more. 

If  the  milk  or  the  kefir  is  not  borne  well,  as 
happens  occasionally,  they  may  be  replaced  by 
soups  of  water  and  starchy  foods,  with  or  without 
the  addition  of  a  little  milk  ;  these  are  to  be  given 
from  two  to  four  times  a  day.  This  diet  pre- 
supposes rest  in  bed,  or  at  least  the  being  confined 
to  the  bedroom. 

2.  When    the    pains    are    less     severe,    the 
diarrhoea-like  motions   less   distressing,   and  the 
abdomen  less  distended,  then,  whether  the  patient 
has  previously  been  put  on  the  preceding  regimen 
or  not,  a  lacto-farinaceous  diet  is  to  be  prescribed, 
in  the  following  form  : 

a.  Breakfast  at  8  a.m. — Kefir  or  milk,  pure  or 
with  the  addition  of  a  little   tea   or  coffee ;  dry 
cake,  or  rusk,  or  crust  of  toast,  with  a  little  fresh 
butter,  or  a  thick  farinaceous  gruel,  boiled. 

b.  Noon. — Lunch  of  two  dishes  and  a  dessert, 

Neurasthenia.  20 


306  NEURASTHENIA. 

chosen  from  the  following  articles  :  thick  boiled 
farinaceous  gruel ;  purees  of  potatoes,  dried  peas, 
or  lentils,  boiled  in  water  and  with  fresh  butter ; 
baked  potatoes,  rice,  macaroni,  "  nouilles," 
pudding,  new  cheese,  stewed  fruit  with  little 
sugar.  The  yolks  of  two  eggs  may  be  permitted. 
Toast  or  rusks. 

c.  At  4  p.m. — Kefir,  or  milk  (with  coffee  or 
tea),  or  cocoa  made  with  water. 

d.  At  7  p.m. — As  at  noon. 

No  liquid  is  to  be  drunk  at  the  noon  or  evening 
meals,  but  a  glass  of  Alet,  or  Evian,  or  some 
other  good  and  mild  mineral  water,  may  be  taken, 
if  desired,  at  10  a.m.  and  bed  time. 

3.  In  the  stage  in  which  the  symptoms  of 
intestinal  fermentation  are  still  slighter,  the 
addition  of  a  little  meat  (grilled  mutton  or  beef, 
lean  ham,  fowl,  hot  or  cold,  beef  a-la-mode  cold) 
may  be  permitted,  first  at  the  mid-day  meal  only, 
and  later  at  both  the  mid-day  and  the  evening 
meal ;  but  the  meat  should  be  accompanied  by  a 
large  dish  (four  or  five  times  as  large)  of  puree  of 
vegetables,  rice  or  macaroni. 

These  diets,  however,  are  only  indications  that 
may  be  modified  according  to  circumstances.  In 
such  matters  we  must  have  ruling  principles 
which  we  must  follow  as  far  as  possible,  without 
forgetting,  however,  that  the  living  organism  is 
not  a  retort,  and  that,  especially  in  the  case  of 
neurasthenics,  we  have  to  reckon  with  questions 


DIET.  307 

of  taste,  repugnance,  appetite,  and  gastric  re- 
actions to  aliments,  that  compel  us  to  make  our 
prescriptions  suit  the  peculiarities  and  special 
indications  of  each  case.  To  know  how  to  do 
this  is  the  distinguishing  mark  of  the  able 
physician. 

In  conclusion,  I  must  say  a  few  words  on  the 
means,  apart  from  diet,  of  calming  the  sufferings 
of  patients  affected  with  painful  membranous 
colitis.  One  often  has  to  exert  oneself  to  this 
end,  for  not  only  are  the  sufferings  often  very 
great,  but  they  produce  in  the  patients,  who  are 
already  very  sensitive  as  a  rule,  reactions  that 
show  themselves  by  insomnia,  despair,  and 
gloomy  ideas.  The  application  of  hot  or  chloro- 
form compresses,  or  sometimes  of  ice,  to  the 
abdomen,  and  above  all  hot  baths,  are  very 
valuable  from  this  point  of  view.  For  internal 
use,  we  must  prescribe  belladonna,  in  pills  of  i 
grain  of  the  extract,  which  may  be  combined  with 
I  grain  to  1^  grains  of  extract  of  valerian,  from 
one  to  four  or  five  pills  being  given  during  the 
day ;  or  codeine  may  be  given  as  the  syrup  in  a 
little  infusion  of  orange  leaves,  or  in  pills  of  & 
grain,  of  which  one  to  five  may  be  administered 
daily. 


CHAPTER   IV. 
HYDROTHERAPEUTICS. 

Hydrotherapeutics  may  prove  of  the  greatest 
service  in  the  treatment  of  neurasthenia.  It  is 
certainly  one  of  the  best  physical  agents  in  the 
domain  of  therapeutics,  and  there  are  very  few 
cases  of  nervous  exhaustion  in  which  its  use  is 
not  formally  indicated.  The  stimulating  and 
tonic  action  exerted  by  cold  applications  on  the 
nervous  centres,  and  through  them  on  the  whole 
organism,  is  especially  beneficial  to  sufferers 
from  nervous  asthenia.  Although  "the  state 
of  irritable  weakness"  that  characterises  this 
neurosis  shows  itself  sometimes  by  signs  of 
asthenia,  sometimes  by  phenomena  of  erethism 
or  excitation,  yet  hydrotherapy,  with  its  stimu- 
lating influence,  is  none  the  less  indicated  to 
combat  these  two  classes  of  symptoms,  because 
their  opposition  is  only  apparent  and  they  are 
due  to  the  same  cause,  debility  of  the  nerve 
centres. 

All  hydrotherapeutic  procedures,  however,  are 
not  equally  applicable  to  the  treatment  of 
nervous  exhaustion.  In  general,  violent  stimuli 


HYDROTHERAPEUTICS.  309 

and  the  too  pronounced  abstraction  of  heat  are 
badly  borne  by  neurasthenics.  The  mildest 
measures  are  by  far  the  best,  and  among  those 
that  seem  to  us  to  give  the  most  thorough  and 
most  permanent  results,  we  may  mention 
sponging,  the  wet  pack,  and  the  cold  shower 
played  over  the  different  parts  of  the  body.  But 
it  is  not  enough  to  prescribe  one  method  or 
another;  it  is  necessary  also  to  show  how  the 
method  chosen  is  to  be  applied. 

Wet  pack  with  friction. — The  wet  pack  may 
be  prescribed  without  danger  in  all  forms  of 
neurasthenia.  A  very  coarse  sheet  is  soaked  in 
water  at  70°  to  75°  F.  and  wrung  out  vigorously. 
The  patient  takes  off  all  his  clothes  and  stands 
upright,  and  the  sheet,  prepared  as  above,  is 
unfolded  and  thrown  rapidly  over  his  shoulders 
and  back,  and  the  edges  are  carefully  brought 
together  in  front  over  the  chest,  abdomen,  and 
limbs.  The  hand  is  then  placed  on  the  wet  sheet 
and  regular  friction  is  immediately  performed  for 
one  or  two  minutes  over  the  whole  surface  of 
the  body;  this  done,  the  sheet  is  removed  and 
the  patient  is  dried  quickly  by  a  second  methodi- 
cal friction  with  another  sheet  that  is  dry  and 
slightly  warmed.  He  then  dresses  and  walks 
about  so  as  to  favour  reaction,  or,  if  he  be  too 
weak,  he  goes  to  bed  for  an  hour  and  the  reaction 
is  not  long  in  coming.  On  the  following  days  the 
temperature  of  the  water  may  be  progressively 


310  NEURASTHENIA. 

lowered  till  it  reaches  60°  F.  This  is  certainly 
one  of  the  mildest  hydrotherapeutic  measures, 
but  yet  it  is  efficacious  enough,  and  its  use  is 
especially  to  be  recommended  in  neurasthenic 
conditions  where  the  indication  is  to  give  tone 
to  the  nerve  centres  without  exciting  the 
peripheral  nerves  too  violently.  This  procedure 
has  the  further  practical  advantage  that  it  can 
be  carried  out  at  home  and  does  not  require  any 
special  apparatus. 

Dripping  wet  pack  without  friction. — This 
method  consists  essentially  in  wrapping  the 
patient  for  one  or  two  minutes  in  a  sheet  that 
has  been  soaked  in  cold  water  but  not  wrung  out, 
and  afterwards  rubbing  him  gently  with  a  dry 
sheet.  This  procedure,  like  the  former,  has  a 
tonic  and  sedative  action,  but  is  less  exciting.  It 
constitutes  in  fact  an  excellent  means  of  training 
and  of  preparation,  and  can  be  employed  with 
advantage  every  time  that  a  patient  cannot  at 
first  support  the  douche  or  friction  with  a  wet 
pack  that  has  been  wrung  out. 

Cold  Sponging. — Cold  sponging  in  the  tub,  with 
a  large  sponge  steeped  in  water,  the  exact 
temperature  of  which  does  not  matter,  may  also 
be  used,  either  to  train  the  patient  to  the  douche 
or  as  a  means  of  continuing  at  home  a  treatment 
that  has  been  begun  in  a  special  establishment. 

Cold  Shower. — The  cold  shower  sprayed  over 
the  different  parts  of  the  body  is  much  more 


HYDROTHERAPEUTICS.  311 

active  than  the  wet  pack.  It  is  the  method  above 
all  others,  and  must  be  prescribed  and  applied  to 
every  patient  who  can  visit  a  hydrotherapeutic 
establishment  daily.  The  shower  must  be 
sprayed  first  on  the  feet  and  calves  and  the  back 
of  the  body,  carefully  avoiding  the  head  and 
neck.  Then  the  patient  turns  round  and  the 
front  of  his  body  is  played  upon.  Finally  the 
water  is  directed  on  the  feet  for  a  few  seconds 
in  an  unbroken  jet.  The  duration  of  the  shower- 
bath  should  be  very  short,  not  exceeding  30 
seconds,  and  if  the  water  be  very  cold,  below 
50°  F.,  6  or  8  seconds  will  be  enough,  at  least  in 
the  beginning  of  the  treatment,  to  produce  the 
desired  therapeutic  action.  "  Too  short  a  shower- 
bath  has  no  disadvantages;  too  long  a  shower- 
bath  is  always  dangerous."  (Fleury). 

In  this  connection,  however,  the  facility  and 
the  greater  or  less  rapidity  with  which  the 
subject  reacts  must  be  taken  into  account,  and 
it  must  not  be  forgotten  that  the  duration  of  the 
shower-bath  should  be  proportional  to  the  sensi- 
tiveness of  each  patient  and  his  state  of  training. 

After  the  shower-bath  the  patient  is  dried  and 
rubbed,  and  takes  moderate  exercise  in  order  to 
facilitate  the  reaction. 

The  hydrotherapeutic  measures  that  we  have 
just  indicated  should,  to  produce  their  complete 
effect,  be  continued  for  a  sufficiently  long  period. 
One,  two,  or  three  months  are  usually  needed  to 


312  NEURASTHENIA. 

arrive  at  the  result  desired.  Whatever  be  the 
procedure  used,  wet  pack,  sponging,  or  cold 
shower,  the  patient  must  not  undergo  more  than 
two  applications  daily.  In  the  majority  of  cases 
there  should  be  only  one  wet  pack  or  shower, 
and  it  should  be  given  in  the  morning  immedi- 
ately on  waking ;  that  is  the  most  favourable 
hour.  Such  we  think  is  the  plan  to  be  followed 
in  the  treatment  of  the  greater  number  of 
neurasthenics. 

Tepid  shower. — Hot  shower. — Scotch  douche. — 
But  the  personal  susceptibilities  of  the  patient 
and  the  coexistence  of  certain  diatheses  sometimes 
render  the  application  difficult,  if  not  impossible. 
We  shall  now  examine  these  difficulties  inherent 
in  the  particular  condition  of  each  subject,  and 
the  special  indications  that  result  from  them. 

When  it  is  thought  right  to  make  use  of  the 
cold  shower  in  the  case  of  a  neurasthenic  who 
manifests  a  marked  repugnance  to  such  a  hydro- 
therapeutic  measure,  it  is  necessary,  before 
applying  the  shower  at  a  temperature  of  45°  or 
50°  F.,  to  train  him  in  some  sort  by  first  using 
less  rigorous  procedures.  It  would,  in  fact,  be 
imprudent  to  take  into  account  neither  his 
pusillanimity,  which  is  often  very  great,  nor  his 
physical  sensitiveness,  which  is  sometimes  very 
real.  By  subjecting  him  at  once  and  without 
caution  to  a  very  cold  or  a  cold  shower,  60°  F.  or 
less,  one  would  run  the  risk  of  making  him  worse 


HYDROTHERAPEUTICS.  313 

for  a  time,  of  inspiring  him  with  an  aversion  to 
hydrotherapy  that  would  prove  unsurmountable 
for  the  future,  and  thereby  of  depriving  him  of 
a  beneficial  mode  of  treatment.  The  patient's 
sensitiveness  may  be  tried  by  making  use  at  first 
of  a  cold  shower,  but  of  very  short  duration  (2  to 
5  seconds  at  most).  When  the  trial  has  been 
made,  then  those  on  whom  cold  water  is  found 
to  make  too  great  an  impression  may  be  acclima- 
tised by  having  recourse  to  either  a  warm  or  a 
luke-warm  shower,  the  temperature  of  which  is 
to  be  progressively  lowered,  or  to  the  Scotch 
douche.  The  former  of  these  two  procedures 
has  been  the  object  of  criticisms  that  seem  to  us 
well  founded.  After  the  luke-warm  or  temperate 
bath,  the  vascular  reaction  is  almost  nil;  the 
patients  have  no  tendency  to  grow  warm  again 
spontaneously ;  they  shiver  and,  as  the  superficial 
chilling  of  the  skin  persists,  the  effect  produced 
is  the  reverse  of  beneficial.  The  cool  shower 
(65°  to  75°  F.)  presents  almost  the  same  disad- 
vantages. The  reaction  of  temperature  that  it 
produces  is  often  insufficient,  and  it  may  provoke 
the  return  or  the  development  of  neuralgic  or 
rheumatic  pains.  The  Scotch  douche  is  a  better 
means  of  preparation  for  cold  water,  and  should 
be  preferred  to  the  preceding  methods.  It 
consists  in  giving  first  a  warm  shower  at  a 
temperature  of  97°  or  98°,  which  is  steadily  and 
fairly  rapidly  raised  to  105°  or  even  113°.  The 


314  NEURASTHENIA. 

shower  is  continued  at  this  maximum  degree  for 
thirty  seconds,  one  minute,  or  two  minutes  at 
most,  and  then  the  temperature  of  the  water  is 
lowered  abruptly,  and  without  passing  through 
intermediate  stages,  to  45°  or  50° ;  the  duration 
of  the  cold  douche  should  not  exceed  ten  to 
fifteen  seconds  (F.  Bottey). 

There  are  some  neurasthenics  who,  no  matter 
what  mode  of  training  is  followed,  cannot  support 
the  action  of  the  shower-bath  even  at  a  moderate 
temperature.  In  these  cases  recourse  must  be 
had,  as  the  final  method  of  treatment,  to  the 
proceedings  without  douches  that  we  have  already 
indicated,  such  as  wet  friction,  sponging,  packing 
in  wet  sheets,  or  even  the  ordinary  hip-bath 
cooled.  Certain  neurasthenics  show  themselves 
altogether  refractory  to  cold  water ;  in  whatever 
manner  it  be  applied  they  experience  so  disagree- 
able a  sensation  at  the  moment  of  contact  with 
it  that  the  cold  water  cure  must  be  definitely 
banished  from  their  treatment. 

There  is  a  class  of  patients  who,  without  being 
too  strongly  affected  by  the  contact  of  the  cold 
shower,  yet  find  that  their  nervous  irritability 
and  their  various  forms  of  malaise  increase  under 
its  influence.  And  sometimes  the  mitigated 
methods  of  cold  sponging  and  wet  friction  are 
hardly  more  successful.  Idiosyncrasies  in  this 
matter  are  met  with  in  practice,  and  must  be 
respected.  Some  of  these  hyperexcitable  patients, 


HYDROTHERAPEUTICS.  315 

however,  bear  fairly  well  immersion  in  the 
plunge-bath  with  still  water  and  at  a  moderate 
temperature  (60°  to  70°  F.),  provided  that  the 
duration  of  the  immersion  does  not  exceed  half  a 
minute  or  a  minute  at  most.  In  this  form  the 
use  of  the  plunge-bath  may  produce  effects  both 
tonic  and  sedative ;  whereas  the  cold  plunge-bath 
with  running  water  brings  on  phenomena  of 
excitation  in  the  majority  of  neurasthenics  that 
must  be  avoided  at  all  costs. 

Temperate  bath. — The  temperate  bath  again, 
at  85°  or  90°,  may  be  ordered  for  these  neuras- 
thenics. When  in  the  bath  the  patient  should 
feel  a  pleasant  coolness  which  does  not  go  so  far 
as  to  produce  shivering.  The  duration  of  the 
bath  will  vary  according  to  the  effect  produced 
on  the  subject.  He  ought  to  leave  the  bath  at 
once  if  shivering  occurs.  At  first  a  keen  sensation 
of  cold  comes  on  in  the  second  or  third  minute ; 
but  in  the  long  run  the  sensitiveness  is  blunted 
and  the  patient  ends  by  remaining  five  minutes  or 
even  more.  It  is  well  to  keep  a  cold  compress 
on  the  head  during  the  bath.  Afterwards  the 
patient  is  simply  to  be  wrapped  in  a  woollen 
blanket.  The  temperate  bath  is  usually  followed 
by  a  moderate  but  sufficient  reaction,  and  its 
tonic  and  sedative  effects  are  very  marked. 

In  the  case  of  rheumatic  or  arthritic  patients, 
cold  water  must  not  be  used  except  with  much 
prudence  and  moderation.  It  is  undeniable  that 


316  NEURASTHENIA. 

cold  applications,  even  of  short  duration,  fairly 
often  arouse  rheumatic  pains  in  these  subjects. 
In  such  cases  it  is  better  to  abstain  from  them 
altogether.  The  tepid  bath  or  the  warm  douche, 
or  else  the  Scotch  douche,  must  then  be  resorted 
to  in  the  hydrotherapeutic  treatment  of  these 
patients. 

Tepid  bath.— The  Tepid  bath  (from  90°  to  97°) 
is  almost  devoid  of  action  on  the  temperature  of 
the  body.  When  accompanied  by  friction  with 
soap  it  makes  the  skin  supple,  revives  its  physio- 
logical functions  and  acts  beneficially  on  the 
peripheral  nerves.  Its  effects  are  chiefly  sedative: 
it  moderates  the  activity  of  the  heart  and  the 
excitability  of  the  nerve  centres,  and  facilitates 
sleep.  The  results  obtained  from  it  in  the  treat- 
ment of  arthritic  neurasthenics  are  all  the  more 
appreciable  because  in  the  majority  of  these 
subjects  symptoms  of  excitement  are  predomi- 
nant. The  duration  of  the  bath  should  be  from 
thirty  to  forty  minutes.  If  prolonged  out  of 
measure,  it  brings  on  fatigue  and  depression.  It 
is  often  followed  by  a  more  or  less  marked  chilling 
of  the  cutaneous  surface.  Hence  care  must  be 
taken  after  every  tepid  bath  to  promote  the 
return  of  heat  to  the  skin  by  energetic  friction 
and  sufficient  wrappings. 

The  warm  dvuche  (90°  to  97°)  produces  a 
sedative  action  in  the  same  way  as  the  warm 
bath ;  it  moderates  the  reflex  excitability  of  the 


HYDROTHERAPEUTICS.  317 

cerebrospinal  system,  calms  cerebral  or  cardiac 
erethism,  and  lessens  insomnia.  Over  the  warm 
bath  it  has  the  advantage  of  being  less  debilitating, 
thanks  no  doubt  to  the  shock  of  the  jet  of  water 
and  the  gentle  stimulation  that  it  gives  to  the 
cutaneous  innervation.  This  douche  must  be 
played  slowly  over  the  different  parts  of  the  body 
for  three  to  ten  minutes.  After  the  warm  douche, 
as  after  the  bath,  the  patient  should  be  vigorously 
rubbed  and  carefully  wrapped  in  a  warm  bathing 
gown. 

The  Scotch  douche  may  be  used  with  advantage 
in  the  treatment  of  arthritic  neurasthenics.  We 
have  already  indicated  the  manner  in  which  it  is 
applied.  It  is  at  once  tonic  and  sedative,  and  has 
not  the  disadvantages  of  the  cold  douche  in  the 
case  of  these  patients. 

Half-bath, — The  half-bath,  which  since  the 
time  of  Priessnitz  has  been  commonly  used  in 
Germany  and  Switzerland,  where  the  douche  is 
less  employed  than  in  France,  may  be  used  for 
excited  neurasthenics,  especially  to  calm  them 
and  bring  on  sleep.  It  has  the  advantage  over 
the  douche  that  the  patients  can  take  it  at  home, 
and  in  the  evening  before  going  to  bed.  It  is 
given,  according  to  Beni-Barbe,1  in  a  large  bath, 
in  which  the  patient  is  made  to  sit  as  comfortably 
as  possible.  The  water  should  not  cover  more 

i  Beni-Barbe,  Expose  de  la  methode  hydrotherapique,  Paris,  1905, 
Masson. 


318  NEURASTHENIA. 

than  the  lower  half  of  the  body,  and  its  tempera- 
ture is  .usually  about  85°F.  at  the  beginning.  If 
the  patient  finds  this  immersion  agreeable,  he  may 
be  left  there  for  some  minutes  without  any 
disadvantage.  At  the  end  of  this  time  taps  are 
turned  on  which  are  arranged  so  as  to  regulate 
the  inflow  and  outflow  of  water  in  an  exact 
manner,  and  in  this  way  the  temperature  of  the 
bath  is  steadily  lowered  by  four,  six,  eight,  or 
even  ten  degrees.  While  this  is  going  on,  water 
must  be  taken  from  the  bath  in  a  pail  or  other 
convenient  receptacle,  and  thrown  over  the  parts 
of  the  patient  that  are  not  submerged ;  and  the 
whole  surface  of  his  body  must  be  rubbed,  the 
lower  parts  with  most  energy.  The  duration  of 
this  immersion  and  the  operations  that  complete 
it  varies  from  five  to  ten  minutes,  according  to 
the  patient's  powers  of  resistance  and  the  degree 
of  his  excitement. 

When  the  patient  leaves  the  bath,  he  is 
sprinkled  with  water  at  an  agreeable  temperature, 
practically  that  of  his  body,  and  he  is  rubbed 
gently,  and  told  to  rest  in  his  bed.  The  operation 
has  usually  a  very  marked  soothing  influence, 
which  produces  an  agreeable  sensation  of  relief, 
and  even  a  restorative  sleep. 

We  must  now  pass  in  review  the  hydrothera- 
peutic  procedures  that  are  specially  applicable  in 
the  treatment  of  certain  predominant  or  funda- 
mental symptoms  of  neurasthenia. 


HYDROTHERAPEUTICS.  319 

For  headache  and  vertigo  moderately  stimula- 
ting applications  are  those  that  suit  best.  But 
they  must  be  used  with  great  prudence,  at  least 
in  the  beginning  of  the  treatment ;  the  cold 
shower  may  be  tried,  the  spray  being  directed 
against  the  lower  limbs  and  lower  half  of  the 
body  only.  It  is  in  these  cases  that  care  must  be 
taken  to  avoid  touching  the  back  of  the  neck  and 
the  upper  part  of  the  back.  Experience  has 
shown  in  fact  that  applications  of  cold  water  to 
this  region  provoke  or  aggravate  vertigo  in 
patients  subject  to  it.  Or  again,  the  treatment 
may  be  commenced — and  this  is  a  more  moderate 
and  more  prudent  manner  of  proceeding — by  giving 
the  Scotch  douche  at  decreasing  temperatures. 

For  those  who  suffer  from  persistent  insomnia, 
the  warm  douche  (from  93°  to  97° F.)  is  to  be 
ordered,  with  a  duration  of  three  to  five  minutes, 
and  striking  the  body  gently.  The  temperate  bath 
at  86°  F.,  of  short  duration  and  combined  with 
colder  affusions  to  the  head,  gives  good  results  in 
cases  of  insomnia  with  marked  prostration. 

The  damp  pack  is  calming  without  being 
debilitating.  It  is  exactly  indicated  in  cases  of 
insomnia.  Here  it  must  be  applied  in  the  patient's 
room  at  the  moment  of  going  to  bed  at  night. 
This  procedure  is  very  efficacious.  The  Germans, 
perhaps,  carry  it  rather  to  excess ;  but  it  certainly 
does  not  deserve  the  oblivion  into  which  it  has 
fallen  in  France.  It  sometimes  succeeds  when 


320  NEURASTHENIA. 

the  douche  and  baths  have  failed.  The  following 
is  the  manner  of  carrying  it  out :  two  woollen 
blankets  are  spread  on  the  bed,  and  over  them  is 
laid  a  sheet  that  has  just  been  wrung  out  after 
having  been  dipped  in  water  at  a  temperature  of 
50°  to  60°  F.  The  patient  lies  down  on  the 
sheet ;  he  is  sprinkled  rapidly  with  some  drops  of 
cold  water,  and  is  then  wrapped  up  so  that  the 
whole  surface  of  his  body  is  in  contact  with  the 
wet  sheet;  the  blankets  are  then  folded  over  him. 
To  obtain  the  desired  tonic  and  especially  the 
sedative  result,  the  patient  is  left  wrapped  up  in 
this  way  for  ten,  fifteen,  or  twenty  minutes.  After 
a  slight  shivering  at  the  beginning,  the  pulse, 
which  was  at  first  quickened,  becomes  slower; 
the  patient  experiences  a  sensation  of  well-being 
and  calm,  sometimes  he  feels  a  general  torpor 
and  somnolence,  and  finally  a  desire  to  sleep  is 
produced.  If  the  damp  pack  be  prolonged  beyond 
the  time  indicated,  there  results  a  diaphoretic 
reaction  that  ought  to  be  avoided. 

For  gastro-intestinal  atony  may  be  ordered  the 
abdominal  douche  in  the  shape  of  a  fan,  the 
dorso-lumbar  douche,  the  alternating  douche 
localised  on  the  abdomen  and  lasting  two  minutes 
(Bouveret),  or  else  the  epigastric  wet  pack.  This 
last  application  produces  a  revulsive  and  excito- 
motor  local  action  that  is  very  beneficial  to 
patients  affected  with  atonic  dyspepsia  and 
constipation.  It  practically  constitutes  a  local 


HYDROTHERAPEUTICS.  321 

vapour-bath.  The  epigastric  or  abdominal  pack 
consists  of  a  linen  or  cotton  band  8  to  14  inches 
wide  and  long  enough  to  go  three  times  round  the 
body.  The  first  turn  only  is  wet,  the  two  other 
turns  are  dry  and  exactly  cover  the  first.  A  flannel 
band  is  put  on  over  all.  The  application  lasts  for 
a  time  varying  from  fifteen  to  thirty  minutes. 

Rachialgia  and  precordial  pains  are  usually 
calmed  by  the  local  application  of  warm  showers 
or  Scotch  douches.  As  to  the  hydrotherapeutic 
procedures  to  be  employed  for  genito-urinary 
symptoms  (spermatorrhoea,  impotence,  neuralgia, 
etc.),  we  shall  describe  them  in  detail  when  we 
set  forth  the  treatment  of  the  genital  form  of 
neurasthenia. 

To  sum  up,  hydrotherapy  ought  only  to  be 
made  use  of  in  the  treatment  of  nervous  asthenia 
with  a  great  deal  of  prudence.  Cold  applications, 
if  given  in  excess,  may  aggravate  the  patient's 
condition.  Account  must  always  be  taken  of  the 
idiosyncrasies  of  the  invalids,  of  their  general 
condition,  and  of  the  leading  disorders  of  which 
they  complain.  It  is  indispensable  at  the  begin- 
ning of  the  treatment  to  test,  so  to  speak,  the 
sensitiveness  of  each  subject,  and  to  observe 
carefully  the  way  in  which  he  reacts;  the  mildest 
methods  are  the  best.  Such  we  believe  are  the 
general  principles  that  should  guide  the  physician 
in  applying  hydrotherapeutic  measures  to  the 
treatment  of  nervous  exhaustion. 

Neurasthenia  21 


CHAPTER  V. 

CLIMATIC  TREATMENT— CHOICE  OF  A 
HEALTH-RESORT, 

It  is  well  known  that  the  majority  of  neuras- 
thenics are  extremely  sensitive  to  atmospheric 
influences.  Both  rigorous  cold  and  excessive 
heat  produce  an  unpleasant  impression  on  them, 
and  are  equally  injurious  to  them.  It  is  certain, 
in  fact,  that  many  of  these  invalids  find  their 
condition  improve  during  the  intermediate  sea- 
sons, and  grow  worse  on  the  other  hand  in  winter 
and  in  summer.  Hence  it  is  temperate  climates 
that  suit  them  best.  Neurasthenics  who  are 
able  to  leave  their  home  for  several  months 
together  should  always  be  advised  to  spend  the 
extreme  seasons  in  a  suitably  chosen  locality.  In 
thus  leaving  the  places  where  they  have  suffered 
for  a  longer  or  shorter  time,  and  where  the 
diverse  exciting  causes  of  their  neurosis  are 
generally  all  united,  they  escape  the  injurious 
suggestive  action  of  their  surroundings  and 
habits,  and  at  the  same  time  they  profit  by  the 
beneficial  influence  exerted  by  residence  in  an 
agreeable  locality  and  a  milder  climate  on  their 


CLIMATIC  TREATMENT.  323 

mental  and  physical  condition.  But  in  this 
chapter  we  propose  to  study  more  especially  the 
hygienic  action  of  different  climates  on  the 
various  classes  of  neurasthenics.  This  study  will 
naturally  lead  us  to  lay  down  with  precision  the 
rules  that  must  guide  the  physician  in  the  choice 
of  a  climatic  health-resort. 

We  shall  examine  successively  the  physiological 
effects : 

1.  Of  mountain  climates  ; 

2.  Of  lowland  climates  ; 

3.  Of  maritime  climates. 

Mountain  climates. — Mountain  life  enjoys  a 
deserved  repute  in  the  treatment  of  neuropathic 
states  and  of  neurasthenia  in  particular.  It  is  in 
summer,  during  the  months  of  July  and  August, 
that  elevated  climates  are  especially  to  be  recom- 
mended. This  climatic  treatment  is  certainly 
preferable,  at  least  for  the  greater  number  of 
neurasthenics,  to  treatment  at  thermal  springs, 
as  well  as  to  residence  in  maritime  resorts. 

The  climatic  characters  of  elevated  health- 
resorts  are  multiple  :  the  atmospheric  pressure  is 
relatively  low  ;  the  temperature  is  lower,  and  the 
difference  between  the  thermometric  mean  of  the 
day  and  that  of  the  night  is  more  marked ;  the 
sky  is  less  cloudy  than  in  plains  and  low-lying 
valleys ;  the  air  is  drier  and  purer ;  the  solar 
radiation  is  greater,  and,  if  the  place  is  suitably 
situated,  strong  atmospheric  currents  are  broken 


324  NEURASTHENIA. 

and  weakened  before  reaching  it  by  the  neigh- 
bouring mountain  chains.  The  locality  chosen 
should  not  be  too  high,  for  it  is  known  that  to 
pass  directly  from  low  regions  to  a  sufficiently 
elevated  altitude  (for  example  5,000  to  6,500  feet 
and  upwards)  produces  peculiar  physiological 
effects  in  normal  subjects ;  these  consist  in 
modifications  of  the  respiration,  the  cardiac 
rhythm,  the  internal  temperature,  etc.  In  his 
work  on  climatic  treatment,  Weber  reports  that, 
out  of  forty-four  individuals  observed  by  him 
under  the  above-mentioned  conditions,  he  found 
that  the  frequency  of  the  pulse  was  hardly 
modified  in  thirty-two,  that  it  was  increased  in 
ten  in  the  proportion  of  5  to  18  per  cent.,  and 
that  it  was  slightly  lessened  in  two.  Out  of 
forty  subjects  who  had  passed  from  low  lying 
plains  to  heights  varying  from  4,000  to  8,000  feet 
above  the  sea  level,  he  also  observed  in  the  first 
few  days  after  the  change  of  altitude  that  the 
number  of  respirations  had  increased  by  from  two 
to  five  inspirations  a  minute.  Out  of  ninety  per- 
sons observed  after  a  stay  of  from  two  to  twenty 
weeks  in  elevated  resorts,  he  found  that  in  the 
majority  the  number  of  respirations  had  not 
varied,  and  that  in  the  others  it  had  either  dimin- 
ished or  increased  by  from  two  to  four  a  minute. 
But  other  observers  have  arrived  at  totally 
different  results. 

The  fact  is  that  the  mental  condition  of  the 


CLIMATIC  TREATMENT.  325 

subject  observed,  his  alimentation,  the  external 
temperature,  and  other  influences  may  modify 
the  rhythm  of  the  respiration  and  the  pulse.  The 
above-mentioned  investigations,  in  spite  of  their 
apparent  precision,  are  surrounded  by  many 
causes  of  error;  hence  it  is  impossible  to  draw 
from  them  reliable  conclusions  as  to  the  action  of 
change  and  degree  of  altitude  on  the  movements 
of  the  heart  and  the  respiratory  apparatus.  This 
is  not  the  case  with  the  modifications  that  have 
been  noted  in  the  composition  of  the  blood.  M. 
Viault1  observed  an  increase  of  the  red  corpuscles 
in  five  persons  who  had  lived  for  a  few  days  only 
at  a  height  of  13,000  feet.  His  investigations 
have  been  taken  up  again,  but  for  a  lower  altitude 
(6,000  feet)  by  F.  Egger.2  This  author's  observa- 
tions were  made  on  twenty-seven  normal  subjects 
or  neurasthenics,  and  he  noted  that  in  a  very 
short  time,  after  a  stay  of  four  or  five  days  on  the 
average,  at  Aros,  the  number  of  red  corpuscles 
increased  from  5,459,666  to  6,357,047  in  a  cubic 
millimetre.  At  the  end  of  several  weeks'  or 
several  months'  residence  the  blood  of  these  same 
subjects  showed  a  slight  further  augmentation  in 
the  number  of  red  cells  (7,000,000  on  the  average). 
The  researches  of  F.  Egger  on  the  parallel  modi- 
fications in  the  haemoglobin  of  the  blood  and  the 
number  of  corpuscles  in  man,  and  his  experiments 

1  Viault,  Comptes  rendus  de  I'Acad.  des  sciences.,  C.  xi. 

a  Fritz  Egger,  in  Handbuch  der  Neurasthenic  von  F.  C.  Miiller. 


326  NEURASTHENIA. 

on  animals  (experiments  which  we  cannot  here 
describe  in  detail),  lead  us  to  believe  that  the 
increase  in  the  corpuscular  richness  of  the  blood 
thus  produced  under  the  influence  of  altitude  is 
quite  real,  that  it  is  only  in  part  attributable  to 
the  concentration  of  the  fluid,  that  is  to  say,  to  a 
diminution  in  the  total  amount  of  serum,  and  in 
fact  that  the  phenomenon  is  one  of  physiological 
adaptation  of  the  constitution  of  the  blood  to  the 
relative  rarefaction  of  the  oxygen  in  the  atmos- 
pheric air.  If  this  interpretation  be  correct,  it 
will  enable  us  to  explain  the  mechanism  of  the 
disorders  exhibited  by  many  normal  subjects 
during  the  first  days  that  follow  their  arrival  at 
altitudes  of  6,500  feet  and  upwards.  These  dis- 
orders, which  are  little  marked,  consist  in  slight 
erethism  of  the  circulatory  system  with  a 
tendency  to  shortness  of  breath  and  a  certain 
state  of  mental  depression.  They  recall  fairly 
exactly  the  symptoms  complained  of  by  anaemic 
patients.  It  is,  then,  to  a  sort  of  relative  oligocy- 
thczmia  that  we  must  ascribe  the  disorders  of 
respiration  and  circulation  observed  in  persons 
who  have  recently  come  into  high  mountainous 
regions.  In  those  who  enjoy  good  health,  the 
physiological  adaptation  to  the  new  conditions  is 
accomplished  rapidly,  and  the  disorders  of  the 
period  of  acclimatisation  are  soon  over.  It  follows 
that  neurasthenics  in  a  state  of  profound  anaemia, 
those  whose  nutrition  is  gravely  affected,  and 


CLIMATIC   TREATMENT.  327 

still  more  those  who  in  consequence  of  age  or  of 
concomitant  constitutional  diseases  are  not  in  a 
state  to  support  this  adaptation,  should  not  go  to 
very  elevated  climatic  health  resorts.  Lofty 
altitudes,  those  that  reach  or  exceed  6,500  feet, 
will  be  of  little  benefit  to  them  and  sometimes 
even  will  not  be  borne.  A  medium  altitude  of 
3,000  to  5,000  feet  is  usually  enough.  Only  those 
neurasthenics  whose  general  condition  has  re- 
mained good,  those  who  suffer  from  a  slight  form 
of  nervous  exhaustion,  and  above  all  convales- 
cents, can  profitably  pass  the  summer  months  at 
higher  altitudes.  Ziemssen  has  with  much  reason 
advised  two  visits  to  the  mountains,  the  first 
about  the  middle  of  spring,  to  a  lower  altitude 
(1,500  to  3,000  feet),  during  which  visit  the  patient 
rests  from  the  fatigues  of  winter  and  accustoms 
himself  to  the  mountain  climate,  the  other  in 
summer,  to  a  higher  altitude. 

To  a  suitable  altitude,  a  good  mountain  health 
resort  must  unite  other  hygienic  conditions.  It 
must  be  sufficiently  sheltered  from  winds.  The 
position  must  be  picturesque  and  such  that  it 
affords  extensive  views.  Again,  the  patients 
must  be  able  without  fatigue  to  find  walks  and 
easy  excursions  in  the  neighbourhood.  Finally, 
the  material  arrangements  must  be  comfortable. 

Experience  has  shown  that  when  all  these 
conditions  are  combined,  a  mountain  climate 
exerts  an  eminently  beneficial  action,  at  once 


328  NEURASTHENIA. 

sedative  and  strengthening,  on  all  the  organic 
functions  and  on  the  nervous  system  of  abnormal 
subjects.  Under  the  influence  of  the  active  life 
in  the  open  air,  of  excursions  over  broken  ground, 
of  the  general  stimulation  due  to  the  freshness  of 
the  air  and  the  solar  radiation,  the  nutritive 
exchanges  are  quickened,  the  appetite  improves, 
and  consequently  a  larger  amount  of  food  is  taken, 
so  that  if  long  walks  and  climbs  are  not 
pushed  to  excess  the  weight  of  the  body  increases 
notably.  Thanks  to  the  activity  displayed  each 
day,  the  muscles  that  aid  in  respiration  gain 
greater  energy,  and  the  inspirations,  if  they  do 
not  increase  in  frequency,  at  least  become  deeper; 
the  contractile  energy  of  the  heart  and  vessels  is 
similarly  increased.  Haematopoiesis  is  more 
complete  and  sleep  is  better.  The  cool  dry  air 
promotes  the  elimination  of  a  larger  quantity  of 
water  vapour.  In  short,  the  nutrition  of  the 
nervous  centres  and  the  other  organs  is  im- 
proved. Such  are  the  physiological  effects  of  a 
mountain  climate  ;  let  us  see  now  what  its  action 
is  on  neurasthenics. 

It  is  certain  that  the  greater  number  of  these 
invalids  benefit  by  this  increase  of  vital  activity 
that  a  stay  in  the  mountains  instils  into  the 
whole  organism.  Some  neurasthenics  at  the 
beginning  of  their  residence,  even  when  the 
altitude  is  only  a  little  more  than  3,000  feet, 
experience  loss  of  breath  and  palpitation  of  the 


CLIMATIC  TREATMENT.  329 

heart,  in  a  word  the  various  troubles  that  may  be 
exhibited,  as  we  have  seen,  by  normal  subjects 
who  go  directly  to  heights  of  6,500  feet,  and 
upwards.  These  patients  must  be  advised  to  rest 
during  the  first  few  days  of  their  acclimatisation. 
The  first  walks  must  be  very  short  and  broken 
by  frequent  halts.  But  at  the  end  of  eight  or  ten 
days  the  initial  discomforts  vanish  completely  ; 
greater  muscular  activity  is  then  to  be  allowed, 
but  it  is  important  that  the  walks  and  excursions 
should  be  regulated  in  such  a  way  that  the 
increase  may  be  progressive.  The  sensation  of 
fatigue  caused  by  them  must  be  only  slight  and 
agreeable,  and  in  no  wise  distressing.  Headache, 
rachialgia,  digestive  disorders  dependent  on 
gastro-intestinal  atony  in  its  slight  form,  muscular 
feebleness,  these  are  the  neurasthenic  symptoms 
that  diminish  most  rapidly  and  most  steadily 
under  the  influence  of  a  mountain  climate.  On 
the  other  hand  insomnia  is  there  as  elsewhere 
the  obstinate  disorder  par  excellence ;  it  rarely 
disappears  completely.  Patients  who  habitually 
sleep  well  sometimes  experience  insomnia  during 
the  first  few  nights  of  their  stay ;  but  this  trouble 
soon  disappears,  like  all  the  other  discomforts  of 
the  period  of  acclimatisation.  There  are,  how- 
ever, some  neurasthenics  whose  sleep  remains 
irregular  and  insufficient  for  the  whole  duration 
of  the  treatment,  and  who  do  not  regain  peaceful 
sleep  till  they  are  once  more  established  in  their 


330  NEURASTHENIA. 

own  homes.  Finally,  there  are  some,  but  these 
cases  are  exceptional,  who  from  the  time  of  their 
arrival  in  the  mountains  are  tormented  by  such 
insomnia  that  they  are  obliged  to  break  off  the 
treatment.  In  this  respect  one  meets  with 
idiosyncrasies,  with  individual  susceptibilities, 
that  it  is  impossible  to  foresee. 

These  general  principles  enable  us  to  lay  down 
the  indications  for  the  employment  of  mountain 
climates  in  the  treatment  of  neurasthenia.  Such 
climates  undeniably  exert  a  stimulant  and  tonic 
action  on  the  nervous  centres,  and  on  the  great 
functions  of  the  economy,  the  circulation,  the 
respiration,  and  the  digestion ;  hence  they  may  be 
recommended  to  the  majority  of  those  suffering 
from  nervous  exhaustion.  They  are  especially 
indicated  in  cases  of  cerebrasthenia  in  which 
symptoms  of  cerebral  depression  predominate, 
when  the  cerebral  asthenia,  the  inability  to  work, 
and  the  headache  have  developed  under  the 
influence  of  intellectual  overpressure  or  prolonged 
troubles  ;  in  cases  of  mild  cerebro-spinal  neuras- 
thenia accompanied  only  by  atony  of  the  digestive 
passages,  or  by  a  slight  degree  of  anaemia ;  and 
finally,  a  residence  among  mountains  is  alto- 
gether beneficial  to  convalescent  neurasthenics 
whose  recovery  is  still  recent  and  needs,  so  to 
speak,  to  be  consolidated. 

On  the  other  hand  the  following  neurasthenics 
must  not  be  sent  to  resorts  whose  altitude  is 


CLIMATIC   TREATMENT.  331 

3,000  feet  or  more :  those  whose  nutrition  is 
already  seriously  involved ;  those  who  suffer  from 
the  severe  form  of  gastro-intestinal  atony  ;  those 
who,  in  consequence  of  the  long  duration  of  their 
ills,  or  of  insufficient  nourishment,  have  fallen 
into  a  state  of  weakness  and  anaemia  that  renders 
them  incapable  of  any  muscular  activity  ;  those 
who  exhibit  very  pronounced  symptoms  of  cere- 
bral excitement;  and  those  in  whom  cardiac 
erethism  has  acquired  great  intensity,  and  who 
suffer  either  from  violent  palpitations  or  from 
permanent  tachycardia.  High  altitudes  are  also 
unfavourable  to  rheumatic  neurasthenics,  to  those 
tormented  by  anxious  obsessions,  notably  by 
agoraphobia,  and  to  those  who  are  subject  to 
frequent  attacks  of  vertigo.  These  different 
classes  of  patients  should  instal  themselves  in 
summer  either  in  the  plains,  or  in  subalpine 
health-resorts  at  a  height  of  1,300  to  3,000  feet 
and  well  sheltered  from  strong  winds.  Again  it 
is  necessary  that  the  resort  they  have  chosen 
shall  afford  all  the  elements  of  the  treatment 
prescribed  (comfort,  medical  supervision,  hydro- 
therapy,  etc).  There  are  in  France,  in  the  Alps 
of  Savoy  and  Dauphine,  several  valleys  admirably 
situated,  and  altogether  suitable  for  the  residence 
of  neurasthenics.  But  the  establishments  found 
in  them  are  usually  defective  in  their  arrange- 
ments, and  consequently  the  majority  of  these 
patients  go  to  Switzerland. 


332  NEURASTHENIA. 

Lowland  Climates. — Lowland  climates  have 
no  specific  action  on  neurasthenic  states.  It  is 
only  indirectly  that  they  benefit  invalids  suffering 
from  nervous  exhaustion.  If  they  aid  in  the 
efficacy  of  the  treatment,  it  is  chiefly  because  the 
patients  who  go  to  live  in  a  selected  health-resort 
leave  their  habitual  surroundings  and  the  causes 
that  have  given  rise  to  their  neurosis,  and  at  the 
same  time  find  a  climate  that  is  more  genial  in 
winter  and  cooler  in  summer  and  that  enables 
them  to  spend  the  greater  part  of  the  day  in 
the  open  air;  they  also  enjoy  more  agreeable 
scenery ;  and,  in  short,  the  sum  total  of  the  new 
sensations  that  they  experience  exerts  a  bene- 
ficial influence  on  both  their  mental  and  their 
physical  condition.  There  is  reason  however  to 
advise  those  neurasthenics  for  whom  mountain 
and  marine  climates  are  counter-indicated,  to 
instal  themselves  by  preference  on  the  shores  of 
the  Swiss  or  North  Italian  lakes,  or  simply  in  the 
country  far  from  the  noise  and  bustle  of  towns ; 
there  only  will  they  find  the  perfect  calm  and  the 
rest  that  they  require.  Apart  from  all  climatic 
action,  country  life  exerts  the  most  salutary 
influence  possible  on  most  of  the  symptoms  of 
neurasthenia.  It  must  especially  be  recommended 
to  those  neurasthenics  who  inhabit  towns.  We 
have  many  times  observed  that  a  stay  of  some 
weeks  in  the  country  is  enough  to  bring  about  an 
improvement  that  several  months'  treatment  in 


CLIMATIC  TREATMENT.  333 

town  had  failed  to  produce.  It  is  especially 
those  neurasthenics  in  whom  symptoms  of 
excitement  predominate  that  are  likely  to  benefit 
by  a  sufficiently  prolonged  residence  in  the 
country  and  the  relative  isolation  that  it  gives. 
Headache,  insomnia,  excitability  of  the  senses 
and  appetites,  and  emotionalism,  such  are  the 
troubles  that  have  seemed  to  us  more  particu- 
larly to  amend. 

Maritime  Climates. — Should  a  stay  at  the  sea- 
shore be  recommended  or  forbidden  to  neuras- 
thenics ?  This  question  is  much  disputed.  Many 
neurasthenics  go  of  their  own  accord  to  the 
Atlantic  coast  in  summer,  and  in  winter  to 
resorts  on  the  shores  of  the  Mediterranean 
(Riviera  di  Ponente,  Hyeres,  Cannes,  Nice,  etc.). 
It  is  undoubted  that  these  invalids  cannot  always 
congratulate  themselves  on  their  visit,  although 
they  may  have  lived  in  the  quiet  and  the 
observance  of  rules  of  life  that  are  appropriate 
to  their  condition.  The  fact  is  that  a  maritime 
climate  does  not  suit  all  neurasthenics.  At  the 
seaside  the  air  is  fresh  and  keen  and  always  in 
motion,  gusts  of  wind  are  frequent,  and  sea-baths, 
even  when  very  short,  have  a  tonic  action  of  the 
most  energetic  kind;  hence  sea-water  and  sea- 
side air  are  not  in  general  beneficial  to  cases  in 
which  symptoms  of  excitement  predominate ; 
they  rather  aggravate  these  symptoms  and 
sometimes  even  bring  on  new  troubles.  Some 


334  NEURASTHENIA. 

patients  who  have  hitherto  slept  soundly  are 
attacked  by  insomnia,  or  wake  frequently  during 
the  night ;  others  complain,  especially  towards 
evening,  of  a  sort  of  vague  malaise  made  up  of 
mental  over-excitement,  of  enervation  accom- 
panied by  marked  acceleration  of  the  pulse,  and 
of  a  feeling  of  heat  in  the  skin  ;  others  again  are 
tormented  by  cardiac  palpitations.  Arthritic 
neurasthenics  suffering  from  hyperaesthesia, 
those  whose  nervous  exhaustion  is  complicated 
by  hysterical  manifestations,  those  who  are 
subject  to  fits  of  anxiety,  and  those  who  are 
under  the  influence  of  intense  moral  depression 
and  who  are  habitually  gloomy  and  show  a  great 
tendency  to  melancholy,  find  themselves  generally 
much  the  worse  for  a  stay  at  the  seaside. 
Similarly,  those  neurasthenics  who  ordinarily 
suffer  from  rheumatoid  pains  frequently  complain 
of  an  aggravation  of  their  sufferings.  All  these 
patients  must  be  warned  against  maritime 
climates,  even  if  very  dry. 

On  the  other  hand  a  stay  at  the  seaside  often 
gives  good  results  in  the  case  of  those  whose 
nervous  exhaustion  has  followed  on  excessive 
physical  fatigue  or  exaggerated  intellectual  work, 
and,  in  general,  in  all  cases  in  which  phenomena 
of  erethism  and  excitement  are  almost  absent 
and  in  which  symptoms  of  languor  and  weakness 
predominate,  such  as  muscular  asthenia,  inca- 
pacity for  work,  or  sluggishness  of  the  digestive 


CLIMATIC   TREATMENT.  335 

functions.1  Patients  who  go  to  reside  at  the 
seaside  should  of  course  instal  themselves  near 
a  quiet  beach,  far  from  fashionable  watering- 
places,  and  should  keep  aloof  from  the  society 
life  led  at  such  places  and  the  thousand  causes 
of  fatigue  and  excitement  that  are  generally 
found  there.  It  is  evident  that  such  a  holiday 
would  hardly  be  healthier  or  more  profitable  to 
the  patient  than  life  in  any  large  town. 

Travelling. — Should  travelling  be  recommended 
to  neurasthenics  ?  No  absolute  rule  can  be 
drawn  up  in  respect  to  this.  It  is  the  same  with 
travelling  as  with  all  other  measures  employed 
in  the  treatment  of  nervous  asthenia:  the  effects 
are  beneficial  or  injurious  according  as  the  treat- 
ment is  prescribed  to  suitable  or  unsuitable  cases. 
The  matter  is  one  of  judgment  and  tact  on  the 
part  of  the  physician. 

It  is  certain  that  many  medical  men  follow  a 
routine  of  advising  all  their  neuropathic  patients 
to  travel.  Now  it  often  happens  that  the 
neurasthenics  who  have  thus  been  transformed 
into  tourists  by  their  doctor's  orders  find  their 
condition  aggravated  after  some  weeks  of 
peregrinations ;  the  majority,  when  their  exodus 
is  over,  remark  with  bitterness  that  they  are  as 
ill  as  they  were  on  the  day  they  set  out.  Beard 
and  Charcot  addressed  strong  ironical  criticisms 
to  those  of  their  colleagues  who  invariably 

1  A  stay  at  the  seaside  often  increases  constipation. — Trans. 


336  NEURASTHENIA. 

prescribed  long  journeys  for  their  neurasthenic 
patients,  without  taking  into  full  account  both 
the  indications  and  the  counter-indications.  In 
order  to  estimate  such  a  method  at  its  true  value, 
it  is  enough  to  picture  to  oneself  these 
neurasthenic  travellers  suffering  from  muscular 
feebleness,  always  tired,  exhausted  by  a  simple 
walk,  and  then  to  imagine  them  embarking  for 
distant  countries,  leaving  the  boat  to  take  the 
train,  going  from  town  to  town,  passing  whole 
days  in  visiting  monuments  and  museums,  making 
continual  excursions,  and  condemned,  dyspeptics 
as  they  are,  to  unceasing  changes  in  their  food 
and  mode  of  life.  It  is  clear  that  such  an 
existence  is  little  calculated  to  restore  the 
balance  and  the  energy  of  their  exhausted 
nervous  system.  It  is  well  known  that  those 
suffering  from  severe  neurasthenia,  debilitated 
subjects,  and  those  affected  with  gastro-intestinal 
atony,  should  remain  quiet.  They  need  a  calm 
and  regular  life.  It  is  evident  that  travelling  in 
no  way  suits  them,  and,  whether  they  stay  at 
home  or  go  to  the  country,  the  mountains,  or  the 
seaside,  once  they  are  installed  in  their  new 
abode  they  should  refrain  from  further  changes 
and  from  excursions  which  would  tire  them  to 
no  purpose.  Cerebrasthenics  only,  who  have 
maintained  all  their  muscular  strength,  and  who 
are  able  to  walk  and  to  accomplish  long  excur- 
sions on  foot  without  feeling  too  tired,  are  able 


CLIMATIC   TREATMENT.  337 

to  profit  by  a  well  arranged  journey.  The 
changing  sights  that  are  unrolled  before  their 
eyes,  and  the  new  and  agreeable  impressions 
that  they  experience  in  the  course  of  their 
wanderings,  act  beneficially  on  their  minds  by 
modifying  their  moral  disposition.  But  even 
these  patients  must  not  indulge  in  their  excur- 
sions immoderately,  they  must  avoid  all  excess 
of  physical  fatigue,  and  above  all  they  must  not 
take  with  them  when  they  leave  home  the 
preoccupations  and  cares  from  which  precisely 
it  is  necessary  to  distract  them.  Unfortunately 
this  last  condition,  important  as  it  is,  is  often 
very  difficult  to  realize.  Of  what  use  is  it,  for 
example,  to  recommend  a  long  and  distant  journey 
to  a  merchant  or  a  manufacturer  if  he  abandon 
his  business  unwillingly  and  if  he  be  accompanied 
by  disquiet  and  the  fear  that  his  affairs  will  be 
carried  on  badly? 

On  the  other  hand,  take  a  man  who  has  been 
attacked  by  cerebral  neurasthenia  in  consequence 
of  excesses,  of  over-pressure,  or  of  some  grief 
connected  with  a  definite  event  that  is  over  and 
done  with;  if  he  set  out  without  regret,  leaving 
no  source  of  disquietude  behind  him,  taking  away 
with  him,  so  to  speak,  the  whole  of  his  moral 
troubles,  this  patient  cannot  fail  to  benefit  by  an 
extensive  journey  that  will  remove  him  for  a 
long  time  from  the  surroundings  in  which  his 
illness  developed.  But  in  the  majority  of  cases 

Neurasthenia.  22 


338  NEURASTHENIA. 

it  is  rather  short  journeys  that  are  indicated. 
Beard  and  Ziemssen  also  advise  changes  for  a 
short  time  to  a  well  chosen  and  not  too  distant 
locality.  "To  all  cerebrasthenics  whose  brain  is 
"  suffering  from  intense  work  or  strong  preoccu- 
"  pations,"  writes  M.  Bouveret,  "  I  advise  a  visit  of 
"  several  days  or  several  weeks  to  the  mountains 
"  of  Switzerland  or  Dauphin^  in  summer,  to  the 
"  shores  of  the  Mediterranean  in  winter.  They 
"  do  not  abandon  their  affairs  completely ;  they 
"  merely  leave  them  willingly  for  a  few  days. 
"They  go  to  obtain  rest  without  carrying  with 
"  them  the  worry  of  feeling  that  their  business 
"  is  in  danger,  as  it  might  be  during  a  long 
"  absence.  When  they  arrive  at  their  destination 
"  they  spend  some  days  there  in  a  state  of  calm 
"  and  in  rest  of  body  and  mind."  This  advice 
seems  to  us  excellent,  for  a  journey  of  this  kind 
can  be  made  two  or  even  several  times  a  year 
without  doing  any  great  harm  to  professional 
occupations.  But  the  patients  must  be  forbidden 
to  indulge  in  too  long  walks  or  in  too  frequent 
excursions  during  their  holiday.  They  must 
absolutely  avoid  all  physical  fatigue. 


CHAPTER  VI. 
EXERCISE  AND  GYMNASTICS. 

When  muscular  exercise  is  taken  in  a  form 
suited  to  the  individual  who  engages  in  it,  it 
produces,  as  is  well  known,  physiological  effects 
of  the  most  beneficial  kind.  It  invigorates  the 
circulation  of  the  blood,  and  increases  the  re- 
spiratory exchanges  by  amplifying  and  quickening 
the  action  of  the  lungs ;  it  also  stimulates  indi- 
rectly the  functional  activity  of  all  the  organs, 
including  the  secretory  glands,  and  raises  the 
general  nutrition  of  the  tissues;  finally,  by 
causing  contraction  of  the  muscular  walls  of  the 
abdomen,  it  produces  a  sort  of  massage  of  the 
hollow  organs  inside  that  cavity  and  thereby 
facilitates  the  passage  of  their  contents.  Inde- 
pendently of  these  local  and  general  effects, 
bodily  exercises  further  produce  a  series  of 
stimuli  to  the  nervous  centres,  the  hygienic  and 
therapeutic  value  of  which  is  indubitable,  and 
which  ought  consequently  to  be  made  use  of  in 
the  treatment  of  neurasthenic  conditions.  But  it 
is  not  enough  to  prescribe  muscular  exercise  in  a 
vague  manner,  leaving  to  the  patient  the  work  of 


340  NEURASTHENIA. 

finding  out  what  kind  and  amount  of  exercise  are 
suited  to  him ;  to  do  so  would  be  to  lay  oneself 
open  to  cruel  disappointments.  It  is  not  un- 
common to  see  a  patient  who  has  aggravated 
his  condition  by  indulging  in  excessive  or  badly 
regulated  muscular  work.  The  choice  and  regu- 
lation of  the  form  of  exercise  constitute  an  im- 
portant element  in  the  treatment  of  neurasthenia 
and  require  the  whole  attention  of  the  physician. 
They  naturally  vary  according  to  the  general 
state  of  the  patient  and  the  degree  and  form  of 
his  malady ;  but  there  is  in  truth  no  case  in  which 
muscular  exercise  should  not  figure  under  one 
shape  or  another  in  the  treatment  of  nervous 
exhaustion. 

There  is  a  whole  group  of  patients  to  whom  it 
would  seem  at  the  first  glance  that  all  muscular 
work  should  be  forbidden  ;  these  are  the  subjects 
who  in  consequence  of  serious  and  prolonged 
gastro-intestinal  disorders  have  fallen  into  a  state 
of  emaciation  and  profound  feebleness,  and  those 
whose  muscular  asthenia  is  extreme  and  whom  a 
few  slight  movements  suffice  to  exhaust.  These 
neurasthenics  however  should  not,  as  one  might 
expect,  be  left  in  absolute  rest.  Complete  mus- 
cular inaction  would  be  as  injurious  to  them  as 
exaggerated  work,  but  it  is  evident  that  only  the 
mildest  forms  of  exercise  suit  these  invalids,  and 
that  for  them  more  than  for  all  others  the  rule  of 
progressive  increase  of  work,  of  slow  and 


EXERCISE   AND   GYMNASTICS.     341 

methodic  training,  must  be  rigorously  obeyed. 
The  neurasthenics  with  whom  we  are  dealing  are 
perpetually  on  the  verge  of  fatigue;  their  reserve 
of  motor  nerve  energy  is,  so  to  speak,  nil,  and  the 
slightest  voluntary  movement  is  enough  to  exhaust 
them.  Hence  the  only  muscular  work  that  can 
be  prescribed  to  them,  at  first  at  least,  is  that 
effected  by  passive  movements  and  massage ; 
though  the  patient  is  at  rest,  the  movements 
communicated  to  him  bring  about  (like  those 
produced  by  voluntary  muscular  contraction,  but 
without  any  expenditure  of  motor  nerve-energy 
and  consequently  without  functional  fatigue  of 
the  nerve  centres)  a  whole  series  of  muscular, 
tendinous,  and  cutaneous  stimuli,  which  are 
transmitted  by  the  sensory  nerves  to  the  cells  of 
the  centres.  These  peripheral  stimuli  caused  by 
massage,  which  is  only  a  form  of  passive  move- 
ment, or  by  communicated  movements  properly 
so-called,  tend  to  arouse  the  physiological  activity 
of  the  motor  nerve-centres ;  they  stimulate  them 
gently ;  and  even  the  mental  image  of  the 
movement  accomplished  aids  in  the  same  result, 
that  is,  in  preserving  the  functional  activity  of  the 
centres  without  tiring  the  patient.  Passive 
exercise  and  massage  offer  the  further  valuable 
advantage  of  promoting  the  peripheral  circulation ; 
hence  they  constitute  the  mode  of  gymnastics  to 
be  preferred  in  the  grave  forms  of  nervous 
exhaustion  and  notably  in  those  cases  in  which 


342  NEURASTHENIA. 

muscular  asthenia  is  well  marked.  That  is  why 
they  figure  so  happily  in  the  systematic  treatment 
recommended  by  Weir  Mitchell  for  the  neuras- 
thenia of  women ;  when  we  explain  his  method 
we  shall  see  that  at  the  beginning  of  the  treatment 
the  patients  are  subjected  to  complete  and 
necessary  muscular  rest,  which  would  cause 
sluggishness  of  the  peripheral  circulation  and 
aggravation  of  the  gastro-intestinal  atony  if 
massage,  passive  movements,  and  faradic  elec- 
tricity were  not  used  to  ward  off  these  disad- 
vantages. And  it  is  only  little  by  little,  when  the 
alimentation  and  the  power  of  assimilation  are 
considerably  improved,  that  the  patient  is  allowed 
to  make  voluntary  movements,  slight  and  infre- 
quent at  first,  but  progressively  increased  in  pace 
with  the  augmentation  of  her  strength  under  the 
influence  of  the  quiet,  the  rest,  and  the  dietary  to 
which  she  is  subjected. 

When  convalescence  has  fully  begun,  when 
these  neurasthenics  are  able  to  stand  up  and  to 
walk  for  a  longer  or  shorter  time  without  be- 
coming tired,  modes  of  exercise  are  thenceforward 
appropriate  that  may  be  made  use  of  from  the 
beginning  in  the  slight  forms  of  nervous  exhaus- 
tion. Cerebrasthenics,  those  who  are  affected 
with  cerebro-spinal  neurasthenia  but  who  exhibit 
a  slight  degree  only  of  muscular  asthenia,  and 
above  all  those  whose  loss  of  motor  power  is  due 
to  enfeeblement  of  the  will,  to  aboulia  or  old 


EXERCISE  AND   GYMNASTICS.     343 

standing  habits  of  idleness,  all  these  should  take 
to  some  active  exercise.  In  such  cases  the 
physician  must  be  able  to  determine  exactly  the 
amount  of  effort  and  to  choose  the  form  of 
movements  that  are  appropriate  to  each  patient ; 
that,  as  M.  F.  Lagrange1  very  justly  remarks,  is 
the  secret  of  treatment  by  exercise ;  it  is  also  a 
problem  that,  in  so  far  as  neurasthenics  are 
concerned,  is  not  always  easy  to  solve. 

Speaking  generally,  it  is  evident  that  exercises 
requiring  much  strength,  gymnastics  with  the 
aid  of  apparatus,  and  athletic  sports  must  be 
systematically  forbidden  to  neurasthenics ;  how- 
ever slight  be  the  degree  of  nervous  exhaustion 
presented  by  the  patients,  these  forms  of 
gymnastics  are  too  rough  ;  they  are  out  of  the 
question  here. 

It  is  natural  exercises  and  games  in  the  open 
air  that  must  be  recommended  to  these  invalids. 
At  the  beginning  of  the  treatment  however,  and 
as  a  preparation  for  free  and  unsystematic 
physical  exercises,  it  will  be  well  to  subject  them 
for  some  time  to  medical  gymnastics  as  employed 
by  the  Swedish  physicians.  We  need  not 
here  describe  this  form  of  gymnastics,  nor  the 
"  mechanical "  gymnastics  invented  by  Zander  ; 
we  may  say  however  that,  more  than  any  other 
form,  it  allows  of  the  exact  measurement  and 
if  necessary  the  localization  of  the  muscular 

1  F.  Lagrange,  la  Medication  par  Vexercice. 


344  NEURASTHENIA. 

exercise.  Hence  it  seems  to  us  to  be  an  excellent 
method  of  training  for  those  neurasthenics  who 
have  for  long  been  accustomed  to  more  or  less 
complete  muscular  inactivity.  When  appro- 
priately applied  it  imposes  on  the  patient  only  a 
graduated  task  always  a  little  below  his  powers, 
and  that  is  a  condition  essential  for  the  progressive 
restoration  of  his  muscular  energy.  But  it  has 
one  serious  disadvantage — its  want  of  attractive- 
ness ;  many  neurasthenics  soon  lose  interest  in 
it.  Medical  gymnastics  then  should  only  be 
utilized,  we  think,  in  the  treatment  of  nervous 
exhaustion  as  a  transitory  measure  and  as  a  stage 
preparatory  to  the  freer  and  more  active  move- 
ments of  exercises  in  the  open  air. 

Games  like  croquet,  tennis  and  football,  and 
athletic  exercises  like  walking,  bicycling,  riding, 
rowing,  etc.,  produce  results  more  generalised 
than  those  of  methodic  gymnastics.  They  are 
better  stimulants  to  the  great  vital  functions, 
respiration  and  circulation,  and  moreover  they 
are  recreations,  which  is  an  advantage  of  great 
importance  in  the  treatment  of  neurasthenic 
states.  The  interest  and  pleasure  that  the 
patients  take  in  them  act  beneficially  on  their 
nerve  centres.  These  recreative  occupations 
remove  hypochondriacal  ideas  and  gloomy 
thoughts  from  the  patient's  mind,  and  at  the 
same  time  restore  his  confidence  in  his  own 
powers.  Consequently,  in  the  absence  of  special 


EXERCISE  AND   GYMNASTICS.     345 

centra-indications,  the  neurasthenic  who  is  able 
to  indulge  in  these  exercises  must  be  left  free  to 
choose  those  that  attract  him  most.  But  the 
physician  must  not  lose  sight  of  the  fact  that 
these  free  and  natural  exercises  must  be 
regulated  and  measured  as  much  as  methodical 
exercises,  and  that  the  principal  of  progressive 
training  must  here  be  more  rigorously  applied 
than  ever.  On  this  condition  only  will  exercise 
be  a  useful  aid  in  the  treatment  of  nervous 
exhaustion. 

If  this  rule  be  not  absolutely  obeyed,  the 
simplest  and  most  natural  exercise,  a  walk  for 
example,  will  not  fail,  if  continued  for  too  long, 
to  produce  overpressure  and  thereby  an  aggrava- 
tion of  the  patient's  state.  The  principle  of  the 
method  recommended  by  Oertel  in  the  treatment 
of  obesity  seems  to  us  to  be  in  every  respect 
applicable  to  the  regulation  of  the  physical 
exercises  permitted  to  neurasthenics. 


PART  VII. 

TREATMENT    OF    SOME    CLINICAL 
FORMS    OF    NEURASTHENIA. 

CHAPTER  I. 

NEURASTHENIA  OF  WOMEN— WEIR 
MITCHELL'S  SYSTEM  OF  TREATMENT. 

We  have  already  sketched  the  clinical  picture 
of  the  special  form  of  nervous  exhaustion  known 
as  neurasthenia  of  women,  so  we  need  not  describe 
it  again  here,  but  shall  merely  recall  its  essential 
features.  The  patients  are  in  an  extremely 
profound  state  of  moral  depression;  discourage- 
ment, powerlessness  of  will,  and  muscular 
asthenia  are  so  marked  in  these  women  that  they 
are  incapable  of  any  effort;  they  languish  in 
perpetual  inactivity  and  remain  constantly  in  bed 
or  on  the  sofa.  So  much  for  their  mental  state  ; 
as  to  their  physical  condition,  it  is  usually  quite 
as  wretched.  Though  some  of  them  preserve  a 
certain  plumpness,  the  majority  are  considerably 
anaemic  and  emaciated,  for,  owing  to  existing  or 
previous  dyspepsia,  they  have  accustomed  them- 
selves little  by  little  to  eat  insufficiently,  either 


NEURASTHENIA  OF  WOMEN.      347 

because  they  fear  the  feelings  of  malaise  that 
accompany  the  work  of  digestion,  or  simply 
because  they  have  lost  the  courage  to  eat;  for 
their  anorexia  is  often  of  the  same  nature  as  that 
of  hysterical  subjects,  that  is  to  say  it  depends 
much  more  on  the  mental  condition  than  on  any 
real  derangement  of  the  digestive  functions.  Dr. 
Weir  Mitchell  has  observed  and  described  these 
cases  in  a  remarkable  manner.  This  author's 
merit  lies  precisely  in  having  been  able  to 
perceive  the  two  fundamental  elements  of  the 
morbid  group  of  symptoms  that  characterises  the 
neurasthenia  of  women :  the  mental  asthenia, 
and  the  denutrition  of  the  body  that  follows  on 
insufficiency  in  the  amount  of  food  taken ;  these 
lend  one  another  mutual  support  and  combine  in 
keeping  up  indefinitely  the  nervous  exhaustion. 
It  was  cases  of  this  kind  that  Weir  Mitchell  had 
in  view  when  he  formulated  the  rules  of  the 
systematic  treatment  that  now  bears  his  name. 
The  characteristic  of  this  treatment  is  that  it  is 
directed  simultaneously  and  methodically  to  the 
mental  and  physical  condition  of  the  patient ;  it 
thus  fulfils  in  the  happiest  manner  the  double 
therapeutic  indication  in  the  treatment  of  the 
neurasthenia  of  women  :  to  restore  fat  and  blood 
to  these  emaciated  and  anaemic  women,  in  order 
to  revive  permanently  the  nutrition  and  activity 
of  the  nervous  centres,  and  at  the  same  time  to 
rouse  their  moral  energy,  for  the  enfeeblement 


348  NEURASTHENIA. 

of  the  will  is  an  obstacle  to  the  success  of  all 
therapeutic  measures. 

This  mode  of  treatment  has  already  given  proof 
of  remarkable  efficacy,  and  although  it  is  applied 
to  serious  and  inveterate  forms  of  neurasthenia, 
it  has  already  placed  many  cases  of  cure  to  its 
credit ;  it  has  caused  the  superiority  of  physical 
agents  over  drugs  to  be  better  appreciated, 
and  the  importance  of  moral  treatment  to  be 
more  strongly  felt.  In  this  way  it  has  been 
the  origin  of  the  progress  accomplished  during 
these  last  few  years  in  the  treatment  of  nervous 
exhaustion. 

We  shall  set  forth  Weir  Mitchell's  method  as 
faithfully  as  possible.  What  constitutes  its 
originality  is  the  rational  association  of  the 
different  hygienic  and  therapeutic  agents  that 
have  been  proposed  for  nervous  exhaustion,  the 
systematic  combination  of  isolation,  rest,  massage, 
electricity,  and  a  special  dietary  tending  to  fatten 
the  patient  by  overfeeding. 

Isolation  is  necessary.  It  is  an  indispensable 
condition  to  the  success  of  the  treatment.  It  must 
be  complete,  rigorous,  and  continued  to  the  end 
of  the  treatment.  Hence  the  patient  must  be 
taken  away  from  her  home  and  deprived  of  all 
communication,  personal  or  written,  with  her 
family.  Dr.  Weir  Mitchell  has  rightly  insisted 
on  the  necessity  of  imposing  this  measure  on  the 
patient  and  her  friends.  Comparative  isolation 


NEURASTHENIA   OF   WOMEN.      349 

is  worthless;  it  causes  the  failure  of  the  treat- 
ment all  the  more  surely  the  older  and  more 
serious  the  affection  is.  "  Once  separate  the 
"  patient,"  writes  Weir  Mitchell,  "  from  the  moral 
"  and  physical  surroundings  which  have  become 
"  part  of  her  life  of  sickness,  and  you  will  have 
"  made  a  change  which  will  be  in  itself  beneficial 
"  and  will  enormously  aid  in  the  treatment  which 
"  is  to  follow.  Of  course  this  step  is  not  essential 
"  in  such  cases  as  are  merely  anaemic,  feeble,  and 
"  thin,  owing  to  distinct  causes,  like  the  exhaus- 
"  tion  of  overwork,  blood-losses,  dyspepsia,  low 
"  fevers,  or  nursing.  ...  I  am  now  speaking 
"  chiefly  of  the  large  and  troublesome  class  of 
"  thin-blooded  emotional  women,  for  whom  a  state 
"  of  weak  health  has  become  a  long  and,  almost  I 
"  might  say,  a  cherished  habit.  For  them  there 
"  is  often  no  success  possible  until  we  have 
"  broken  up  the  whole  daily  drama  of  the  sick- 
"  room,  with  its  little  selfishness  and  its  craving 
"  for  sympathy  and  indulgence.  Nor  should  we 
"  hesitate  to  insist  upon  this  change,  for  not  only 
"  shall  we  then  act  in  the  true  interests  of  the 
"  patient,  but  we  shall  also  confer  on  those  near 
"  to  her  an  inestimable  benefit."  Thus  then  it  is 
really  necessary  to  remove  the  patient  from  the 
surroundings  in  which  she  has  suffered  for  so  long, 
and  from  the  exaggerated  cares,  the  incessantly 
renewed  commentaries  on  her  discomforts  and 
disorders  that  are  showered  on  her  by  those  about 


350  NEURASTHENIA. 

her,  and  the  only  result  of  which  is  to  cultivate 
the  state  of  mental  depression  and  discourage- 
ment that  keeps  up  and  aggravates  her  illness. 

Whenever  it  is  possible,  the  patient  should  be 
placed  in  a  special  establishment  where  there  is 
a  physician  who  will  supervise  the  carrying  out 
of  the  therapeutic  measures  of  which  the  treat- 
ment is  composed.  A  nurse  should  be  told  off  to 
attend  her.  The  choice  of  this  nurse  is  not  a 
matter  of  indifference ;  the  success  or  failure  of 
the  treatment  may  depend  on  it.  The  nurse's 
functions  are  of  the  highest  importance ;  she  must 
not  only  be  sufficiently  trained  to  execute  the 
physician's  orders  satisfactorily;  she  must  also 
be  well  enough  endowed  in  respect  of  intelligence 
and  character  to  understand  thoroughly  the  task 
she  has  undertaken,  and  to  bring  to  it  all  the  tact 
and  firmness  required.  It  must  not  be  forgotten 
that  this  woman  will  be  for  weeks  and  for  months 
the  patient's  only  companion.  She  must  be 
amiable  and  kindly  enough  not  to  inspire  her 
charge  with  hatred  or  aversion,  skilful  enough 
to  distract  her  by  conversation  and  reading,  and 
to  help  her  to  support  patiently  both  the  details 
of  the  treatment  ordered  and  the  weariness  of  a 
long  isolation ;  and  finally,  firm  and  intelligent 
enough  to  have  a  certain  ascendency  over  her, 
and  to  impose  on  her  without  harshness  the 
discipline  of  the  treatment.  It  is  easy  to  see  that 
it  would  be  absurd  to  give  to  a  woman  of  cultivated 


NEURASTHENIA   OF  WOMEN.      351 

mind  a  nurse  who  was  altogether  illiterate  and 
uneducated,  or  as  we  have  occasionally  seen 
done,  a  quite  young  girl  without  experience  or 
authority. 

When  thus  separated  from  the  outer  world,  the 
invalid  must  receive  no  other  visits  than  those  of 
her  doctor.  It  is  the  latter's  business  to  exert 
that  suggestive  and  cheering  action  on  the 
patient's  mind  that  is  so  necessary  for  the  raising 
of  her  moral  energy,  and  to  restore  to  her  by  his 
words  and  his  bearing  the  confidence  she  has  lost 
and  the  will  to  get  well.  We  have  already 
mentioned  how  delicate  and  difficult  this  task  of 
the  physician's  is,  and  how  much  patience  and 
tact  it  requires. 

It  fairly  often  happens  that  the  isolation  is 
badly  borne  by  the  patient  during  the  first  days 
that  follow  her  sequestration.  The  neurasthenic 
disorders  become  worse,  and  the  patient  grows 
enervated  and  agitated,  and  demands  imperatively 
to  be  taken  home.  But  all  this  emotion  and  this 
agitation  are  quickly  calmed  if  by  his  language 
and  bearing  the  physician  makes  her  feel  that  her 
supplications  are  useless,  and  that  she  will  revolt 
in  vain  against  an  enlightened  will  that  is  superior 
to  her  own.  The  greater  number  of  patients  soon 
adapt  themselves  to  their  new  existence,  and 
moreover  the  hours  of  the  day  are  easily  filled 
up  by  meals,  the  applications  of  massage  or 
electricity,  the  doctor's  visits,  conversation  and 


352  NEURASTHENIA. 

reading,  which  break  at  regular  intervals  the 
monotony  of  the  seclusion. 

The  time  the  isolation  lasts  necessarily  varies 
in  different  cases.  The  average  is  two  to  three 
months.  The  isolation  should  not  come  to  an 
end  till  the  patient's  mental  condition  is  pro- 
foundly improved,  and  she  has  regained  such 
moral  energy  and  activity  of  mind  that  she  can 
resume  her  occupations  and  her  normal  life 
without  giving  way  under  them. 

Rest  is  another  element  of  Weir  Mitchell's  treat- 
ment which  is  quite  as  indispensable  as  isolation. 
During  the  early  weeks  of  the  treatment  it  must 
be  complete,  absolute.  The  patient  is  placed  in  a 
state  of  total  inactivity ;  she  is  kept  in  bed ; 
comparative  silence  is  imposed  on  her ;  all  active 
occupation  is  forbidden  her ;  she  must  neither 
get  up  nor  make  use  of  her  own  hands  under  any 
pretext.  The  nurse  must  feed  her,  lift  her  if 
need  be,  treat  her  in  fact  as  if  she  were  suffering 
from  a  grave  adynamic  fever.  The  American 
author  insists  on  the  necessity  of  this  absolute 
rest  of  the  intellect,  the  senses,  and  the  muscular 
system.  This  condition,  he  says,  is  eminently 
favourable  to  the  repair  of  the  nerve  centres,  the 
restoring  of  the  motor  force,  and  the  soothing  of 
painful  sensations.  Moreover,  as  soon  as  the 
patients  commence  to  feel  its  salutary  influence, 
they  begin  to  desire  movement,  and  to  wish 
ardently  for  their  return  to  activity,  and  this 


NEURASTHENIA   OF  WOMEN.      353 

disposition  of  the  mind  is  a  further  valuable 
adjuvant  to  the  treatment  of  muscular  asthenia. 

But  if  immobility  has  its  advantages,  it  has 
also  serious  inconveniences ;  it  tends  to  diminish 
the  appetite,  to  increase  the  gastro-intestinal 
atony  and  the  constipation,  and  finally  to  main- 
tain the  peripheral  circulation  in  a  state  of  torpor, 
injurious  to  the  general  metabolism.  It  is  to 
obviate  these  disadvantages  that  Weir  Mitchell 
has  very  ingeniously  associated  massage  and  fara- 
disation of  the  muscular  masses  with  rest  in  bed. 

Massage  must  be  carried  out,  as  far  as  possible, 
by  the  nurse.  It  acts  on  the  skin,  the  circulation 
and  secretions  of  which  it  invigorates,  and  on  the 
muscles  by  stimulating  their  action  and  thereby 
their  nutrition.  It  also  causes  a  marked  accelera- 
tion of  the  heart,  and  even  a  slight  increase  in  the 
excretion  of  urea  (Weir  Mitchell).  It  is  performed 
as  follows.  After  coating  the  cutaneous  surface 
with  vaseline  or  oil  of  sweet  almonds  made 
slightly  aromatic,  the  first  manipulation  is  prac- 
tised; this  consists  in  pinching  and  rubbing  the 
skin,  which  is  taken  between  the  thumb  and  the 
other  fingers  so  as  to  be  freely  moved  over  the 
subcutaneous  cellular  tissue.  It  is  necessary  to 
act  very  gently  at  first ;  then  the  force  and  dura- 
tion of  the  mechanical  effort  are  progressively 
increased.  The  frictions  must  be  performed  with 
the  ulnar  border  or  with  the  flat  of  the  hand,  and 
must  proceed  from  the  distal  to  the  proximal 

Neurasthenia.  23 


354  NEURASTHENIA. 

extremity  of  the  limbs.  To  knead  the  muscles, 
the  different  parts  of  them  are  worked  over  with 
the  carpal  regions  of  the  hands  or  the  external 
borders  of  the  thumbs;  then  percussion  is  applied 
with  the  ulnar  border  of  the  hand,  the  blows 
being  slight  and  quick.  During  these  manipula- 
tions the  patient  must  be  entirely  submissive,  and 
must  refrain  from  resistance :  her  muscles  must  be 
in  a  state  of  complete  relaxation,  and  therefore  the 
different  segments  of  the  limb  must  be  placed  in 
the  position  most  favourable  to  relaxation.  The 
manipulations  must  be  carried  out  successively 
on  the  different  segments  of  the  limbs,  and  on  the 
muscles  of  the  back  and  abdomen.  The  muscles 
of  the  face  and  neck  only  are  to  be  spared. 

Massage  of  the  abdomen  acts  efficaciously 
against  constipation.  It  consists  in  a  series  of 
operations  of  friction  and  pressure,  gentle  at  first, 
then  more  and  more  energetic,  and  carried  along 
the  large  intestine,  following  the  direction  of  the 
ascending,  the  transverse,  and  the  descending 
colon. 

Finally  it  is  necessary  to  apply  passive  move- 
ments as  extensive  as  possible  to  the  different 
joints. 

In  the  serious  cases  of  neurasthenia  with  which 
we  are  now  dealing,  the  applications  must  be 
short  at  the  beginning  of  the  treatment ;  twenty 
minutes  are  enough  at  first,  and  then  the  time  is 
steadily  increased — but  it  must  never  exceed 


NEURASTHENIA   OF  WOMEN.      355 

three  quarters  of  an  hour  or  an  hour  at  most. 
The  applications  must  be  daily.  If  well  carried 
out,  massage  produces  neither  pain  nor  excessive 
fatigue.  In  the  regions  which  are  the  seat  of 
hyperaesthesiae  or  of  pains,  it  is  of  course 
necessary  to  proceed  with  much  gentleness,  at 
least  in  the  early  applications.  The  patients  soon 
become  accustomed  to  the  treatment,  and  after 
some  days  they  support  energetic  friction  and 
pressure  in  parts  where  the  slightest  touch  was 
formerly  enough  to  produce  sharp  pain. 

Faradic  electricity  applied  to  the  masses  of 
muscles,  by  bringing  about  repeated  contractions, 
produces  effects  almost  identical  with  those  of 
massage.  Weir  Mitchell  recommends  slowly 
interrupted  currents  as  being  better  borne  than 
those  rapidly  interrupted.  If  massage  is  prac- 
tised in  the  morning,  faradisation  .is  applied  in 
the  afternoon.  The  length  of  the  application  is 
about  twenty  to  thirty  minutes. 

All  these  manipulations,  all  these  mechanical 
stimulations  applied  to  the  skin  and  muscles,  help 
to  produce  the  same  effect:  they  maintain  the 
activity  and  nutrition  of  the  muscles  and  joints 
while  leaving  the  nerve  centres  in  complete 
idleness;  they  are  in  reality  passive  muscular 
exercises,  the  good  effects  of  which  make  them- 
selves felt  in  the  digestive  functions,  the  circula- 
tion and  the  general  nutrition,  in  other  terms 
they  are  a  mode  of  gymnastics  in  the  carrying 


356  NEURASTHENIA. 

out  of  which  the  encephalic  and  spinal  nerve- 
centres  take  no  part. 

The  duration  and  the  arrangement  of  rest  and 
massage,  as  carried  out  by  Weir  Mitchell  in  the 
treatment  of  the  serious  form  of  neurasthenia, 
are  as  follows.  The  patient  is  kept  at  complete, 
absolute  rest  for  the  first  few  days ;  after  seven 
or  eight  days  of  immobility  she  is  allowed  to  sit 
up  in  her  bed  for  one,  two,  or  three  hours  daily. 
Towards  the  end  of  the  third  or  fourth  week  she 
is  permitted  to  get  up  and  remain  sitting  for  one 
or  two  hours  either  in  the  morning  or  in  the 
afternoon;  in  the  second  half  of  the  second 
month  she  is  allowed  to  be  up  for  six  or  eight 
hours,  and  it  is  then  that  the  patient  begins  to 
walk.  Her  walks  are  limited  at  first  to  a  few 
steps.  It  is  advisable  for  the  physician  to  be 
present  at  these  early  attempts,  in  order  that  he 
may  himself  regulate  the  manner  and  duration  of 
them  in  such  a  way  as  to  increase  the  muscular 
exercise  progressively. 

In  the  third  month  the  invalid  has  become  a 
convalescent,  and  little  by  little  regains  the  full 
activity  of  a  woman  in  good  health,  and  in 
favourable  cases  she  is  then  bidden  to  return  to 
ordinary  life.  But  it  is  clear  that  there  are  no 
absolute  rules,  and  that  the  amount  of  rest  and 
of  exercise  must  be  measured,  at  the  time  when 
improvement  declares  itself,  according  to  the 
indications  of  each  individual  case. 


NEURASTHENIA  OF  WOMEN.      357 

As  to  massage,  it  is  advisable  not  to  have 
recourse  to  it  till  after  five  or  six  days  of  com- 
plete rest.  The  applications  are  at  first  to  be 
made  daily  and  to  be  very  short  (from  20  to  30 
minutes);  then  the  duration  is  to  be  steadily 
increased  till  it  becomes  one  hour.  Towards  the 
end  of  the  treatment,  when  the  patient  begins  to 
walk,  the  applications  are  shortened  again  to  half 
an  hour,  and  then  they  are  made  on  alternate 
days  only.  Massage  and  faradisation  are  stopped 
altogether  when  the  patient  is  able  to  be  up  and 
about  during  the  whole  day. 

Dietary  ;  overfeeding. — This  dietary  is  of  great 
importance,  but,  before  beginning  it,  it  is  indis- 
pensable to  examine  the  condition  of  the  gastric 
functions.  It  is  well  borne  when  the  patient  is 
only  affected  with  gastro-intestinal  atony,  and 
better  still  when  the  anorexia  is  almost  exclu- 
sively dependent  on  the  mental  state,  and  in  fact, 
like  hysterical  anorexia,  is  merely  of  the  nature 
of  a  fixed  idea.  On  the  other  hand  the  method 
must  be  applied  with  more  prudence  and  modera- 
tion in  dealing  with  an  invalid  who  has  long 
suffered  from  dyspepsia,  and  who  has  arrived  at 
the  stage  of  permanent  dilatation  with  stasis  and 
acid  fermentations.  In  cases  where  the  dilatation 
is  eventually  complicated  by  catarrh  of  the 
stomach,  it  seems  to  us  preferable  to  aim  at 
improvement  of  the  gastric  functions,  and  to 
obtain  it  by  local  treatment  adapted  to  each  case, 


358  NEURASTHENIA. 

before  subjecting  the  patient  to  Weir  Mitchell's 
dietary.  The  following  are  the  dietetic  precepts 
formulated  by  that  author.  In  almost  every  case 
we  begin  with  a  milk  diet.  The  patient  drinks 
4  or  5  pints  of  milk  daily,  taking  half  a  pint  at  a 
time  every  two  hours.1  After  seven  or  eight  days 
of  milk  diet  she  takes  a  light  lunch  at  noon,  con- 
sisting of  a  cutlet.  Then,  at  the  end  of  three  or 
four  days  more,  the  amount  of  food  is  pro- 
gressively increased  by  adding  a  slice  of  bread 
and  butter  two  or  three  times  a  day.  About  the 
tenth  or  fifteenth  day  the  invalid  takes  three 
complete  meals,  but  still  drinks  3  or  4  pints  of 
milk,  either  at  meals  or  in  the  intervals.  From 
the  twentieth  day  she  is  also  given  at  meal  times 
about  4  oz.  of  liquid  malt-extract  with  the  object 
of  aiding  digestion.  Beef-tea  may  also  be  pre- 
scribed; this  is  prepared  in  the  water-bath, 
several  drops  of  Hydrochloric  Acid  are  added, 
and  the  infusion  is  filtered. 

Dr.  Weir  Mitchell  considers  that  butter  should 
play  a  large  part  in  the  alimentation.  In  winter 
he  prescribes  one  or  two  ounces  of  cod-liver  oil, 
and  if  this  fatty  substance  is  badly  borne  by  the 
stomach,  he  orders  it  to  be  taken  as  an  enema 
mixed  with  an  infusion  of  pancreas  prepared  at 
a  temperature  of  140°  to  176°  F.  Finally  he 

i  Weir  Mitchell  says :  "  It  ought  to  be  given  at  least  every  two 
hours,  at  first  in  quantities  not  to  exceed  four  ounces.  .  .  . 
I  increase  it  in  a  few  days  up  to  two  quarts,  given  in  divided  doses 
every  three  hours."  Fat  and  Blood,  7th  edition,  pp.  Ill,  124. — 
Trans. 


NEURASTHENIA   OF  WOMEN.      359 

allows  a  certain  amount  of  alcohol  in  the  form 
of  a  few  drops  of  whisky  or  two  glasses  of 
champagne. 

All  the  drugs,  bromides,  chloral,  morphine,  etc., 
that  these  patients  are  for  the  most  part  accus- 
tomed to  use  and  even  to  abuse,  must  be  sup- 
pressed. Weir  Mitchell  limits  himself  to  advising 
one  or  two  grains  of  aqueous  extract  of  aloes  to 
be  taken  in  the  evening  if  there  be  constipation. 
He  also  prescribes  iron  in  cases  of  anaemia. 

Such  is  the  mode  of  treatment  recommended 
by  the  American  author  in  grave  and  inveterate 
forms  of  the  neurasthenia  of  women.  It  aims, 
as  we  said  in  the  beginning  of  this  chapter,  at 
the  two  main  symptoms  of  that  neurasthenic 
condition,  namely  the  depression  of  the  moral 
energy  and  the  will,  and  the  emaciation  and 
anaemia  caused  by  insufficient  alimentation.  If 
one  reflects  a  little  on  the  indications  given  by 
such  a  group  of  symptoms,  it  will  be  recognised 
that  these  indications  are  perfectly  fulfilled  by 
this  treatment,  a  treatment  from  which  drugs  are 
excluded  and  in  which  psychical  and  hygienic 
therapeutics  do  all  the  work. 

In  England  Dr.  Play  fair  has  helped  largely  to 
spread  Weir  Mitchell's  treatment.  In  France, 
Charcot,  M.  Bouveret,  and  some  other  clinical 
observers  (ourselves  among  the  rest)  have  also 
tried  it  with  success.  If  it  sometimes  produces 
only  a  temporary  improvement,  in  a  very  large 


360  NEURASTHENIA. 

number  of  cases  on  the  other  hand  it  has  caused 
complete  and  definite  cure.  Hence  we  may 
confidently  proclaim  its  very  real  value. 

In  Germany,  Leyden,  Binswanger,  and  Burkart 
have  modified  Weir  Mitchell's  dietary  more  or 
less  happily. 

Leyden  recommends  the  following  regimen  of 
over-feeding : 

Morning. 

7  a.m.     Two  tumblerfuls  of  milk,  to  be  taken  in 

30  minutes. 

8  One  small  cup  of  coffee  with  cream,  3 

oz.  of  cold  meat,  3  slices  of  white 
bread  and  butter,  1  plate  of  fried 
potatoes. 

10  Two  tumblerfuls  of  milk,  3  rusks. 

Noon         Two  tumblerfuls  of  milk. 

Afternoon. 

1  p.m.     Soup ;    7   oz.   of   chicken.       Potatoes ; 

vegetables ;  stewed  fruit.     Pastry. 
3.30        Two  tumblerfuls  of  milk. 
5.30        3  oz.  of  roast  beef;   2  slices  of  white 

bread  and  butter. 
8  Two  tumblerfuls  of  milk. 

9.30        Two  tumblerfuls  of  milk,  1  rusk. 

To  patients  who  feel  a  strong  aversion  to  milk, 
Binswanger  recommends  the  following  dietary  : 

During  the  first  and  second  week  of  treatment : 
7  a.m.     5  oz.  of  cocoa  made  with  milk. 


NEURASTHENIA  OF  WOMEN.      361 

9  a.m.  1  cup  of  beef-tea,  1  oz.  of  Graham's 
bread  (whole- meal  bread),  and  ^  oz. 
butter. 

11  1  glass  of  white  Hungarian  wine  and  the 

yolk  of  1  egg. 

1  p.m.  3  or  4  oz.  of  soup ;  1  Ib.  of  roast  beef, 
^  oz.  of  potatoes,  i  oz.  of  other  vege- 
tables ;  |  oz.  of  rice  pudding. 

4  Two  tumblers  of  milk. 

6  |  oz.  of  meat,  f  oz.  of  bread,  ^  oz.  of 

butter. 

8  A  breakfast   cupful   of   soup  with  the 

yolk  of  1  egg. 
9.30        A  tumblerful  of  milk. 

And  during   the  third,  fourth,  fifth,  and  sixth 
weeks : 

7  a.m.     5  oz.  of  cocoa  made  with  milk. 

9  1    cup   of    beef -tea  ;    2    oz. .  of    meat ; 

2  oz.  of   Graham's   bread ;   £  oz.  of 

butter. 
11  1  glass  of  Hungarian  wine  and  the  yolk 

of  1  egg. 
1  p.m.     1  oz.  of  soup ;  3  oz.  of  roast  meat ;  2 

oz.  of  potatoes ;  li  oz.  of  vegetables ; 

2£  oz.  of  pudding  with  sugar;  2  oz. 

of  stewed  fruit. 

4  A  breakfast  cupful  of  cocoa. 

6  4  oz.  of  roast  meat ;  2  oz.  of  bread,  i 

oz.  of  butter. 


362  NEURASTHENIA. 

8  p.m.     A  breakfast  cupful  of  soup  (with  f  oz. 

of  butter  and   the   yolk   of    1   egg) ; 

stewed  fruit. 
9.30        Two  tumblerfuls  of  milk. 

These  authors  have  also  endeavoured,  but 
without  success,  to  formulate  precisely  the  in- 
dications and  centra-indications  of  the  method. 
Burkart  and  Leyden  consider  that  isolation  away 
from  the  family  is  a  bad  condition  for  patients 
who  show  symptoms  of  excitement;  and  that  Weir 
Mitchell's  systematic  treatment  does  not  suit 
either  cerebrasthenics  or  those  suffering  from 
visceral  pains  or  from  neuralgic  pains  in  the 
limbs.  Burkart  rightly  calls  attention  to  the  fact 
that  if  the  patients  are  to  benefit  by  Weir 
Mitchell's  treatment,  they  must  have  some  un- 
derstanding of  the  end  pursued.  This  author 
moreover  has  applied  the  method  to  almost  all 
forms  of  neurasthenia  in  men  and  women.  In 
his  latest  publication l  he  gives  the  results  that  he 
has  obtained  in  43  cases.  Out  of  these  43  cases 
31  have  been  cured,  but  these  figures  include 
some  cases  of  hysterical  affections. 

To  sum  up,  we  believe  that  till  we  have  gained 
further  knowledge  the  best  plan  is  to  adhere  to 
the  indications  laid  down  by  Dr.  Weir  Mitchell 
and  Dr.  Playfair. 

l  Burkart. — Die  Behandl.  der  Hysteric  und  Neurasthenie,  Berlifter 
Klin.  Wochensckrift,  1891,  No.  47. 


CHAPTER   II. 
TREATMENT  OF  GENITAL  NEURASTHENIA, 

The  treatment  of  this  form  must  aim  more 
especially  at  improving  the  physiological  condi- 
tion of  the  genital  organs,  and  above  all  at  modi- 
fying the  patient's  mental  state  which  is  always 
profoundly  disordered.  Local  treatment  is  here 
of  great  importance.  Beard,  in  his  monograph 
on  genital  neurasthenia,  insists  at  great  length  on 
this  point.  And  certainly  it  is  right  to  check  the 
urethral  discharge  when  chronic  blenorrhagia  has 
been  the  starting  point  of  the  nervous  disorders, 
to  treat  prostatic  catarrh,  and  to  combat,  ac- 
cording to  the  case,  either  the  increased  excita- 
bility or  the  atony  of  the  centre  for  erection  or 
the  centre  for  emission.  But  it  seems  to  us 
indispensable  to  start  psychical  treatment  from 
the  very  first.  The  patient's  mental  condition 
must  be  acted  on  as  energetically  as  possible, 
because  this  mental  condition  causes  and  controls 
a  large  part  of  the  functional  disorders  of  the 
genital  organs.  The  psychical  treatment  of  the 
invalid  should,  we  think,  precede  the  application 
of  the  various  procedures  intended  to  act  on 


364  NEURASTHENIA. 

the  local  condition  ;  otherwise  it  will  fre- 
quently happen  that  all  the  details  of  treat- 
ment prescribed  with  the  object  of  diminishing 
the  irritability  or  increasing  the  tone  of  the 
genital  organs,  will  only  aggravate  the  patient's 
uneasiness  by  confirming  his  belief  in  the  gravity 
or  the  incurable  nature  of  his  functional  troubles. 
If  care  be  not  taken  to  prepare  his  mind  before 
subjecting  him  to  the  local  applications  of  hydro- 
therapy  or  electrotherapy  that  are  indicated  in 
such  cases,  one  will  run  the  risk  of  cultivating 
instead  of  combating  his  hypochondriacal  ideas,  of 
augmenting  his  genital  impotence,  in  short,  of 
arriving  at  a  result  exactly  the  contrary  of  that 
desired. 

The  patients  with  whom  we  are  dealing  here 
are  in  a  constant  state  of  depression ;  their 
minds  are  dominated  by  a  feeling  of  humiliating 
inferiority,  and  their  depression  is  mixed  with  a 
certain  amount  of  shame.  If  masturbators,  they 
believe  themselves  unable  ever  to  give  up  their 
evil  habit ;  those  who  have  fallen  into  neuras- 
thenia from  excessive  sexual  intercourse,  and 
those  who  are  affected  with  comparative  impo- 
tence, believe  themselves  threatened  with  irre- 
mediable loss  of  their  virility,  or  else  with  an 
incurable  disease  of  the  spinal  cord  ;  the  seminal 
losses  and  the  discharges  of  prostatic  fluid  to  which 
they  are  frequently  liable,  affect  them  keenly ; 
some  imagine  that  these  losses  exhaust  them, 


GENITAL   NEURASTHENIA.         365 

others  that  they  are  due  to  some  grave  lesion  of 
the  internal  organs,  and  when  these  symptoms 
develop  themselves  in  young  men  who  are  in  a 
position  to  marry  before  long,  the  mental  upset 
that  follows  is  complete.  The  physician  must  set 
himself  to  reassure  these  patients  ;  to  explain  to 
them  that  the  functional  disorders  from  which 
they  suffer  are  perfectly  curable ;  and  to  make 
them  understand  the  part  played  by  their  mental 
attitude  and  their  worries  in  developing  and 
keeping  up  these  disorders.  The  comparative  impo- 
tence that  sometimes  accompanies  the  phenomena 
of  excitement  of  the  initial  stage,  is  of  psychical 
nature  ;  those  affected  with  it  must  be  reassured 
by  being  reminded  that  they  are  capable  of 
experiencing  erections  when  alone,  and  that  the 
cause  of  their  impotence  at  the  moment  of  coitus 
lies  principally  in  the  moral  fear  and  agitation 
with  which  they  enter  upon  the  sexual  act.  As 
to  the  neurasthenics  suffering  from  real  genital 
atony  and  absolute  impotence,  we  think  that  one 
ought  to  combat  the  strong  hypochondriacal  pre- 
occupations of  which  this  impotence  is  the  source, 
by  proving  to  them,  as  M.  Ultzmann  advises,  that 
they  are  still  capable  of  strong  erections.  For  in 
fact  it  is  possible  to  excite  erection  in  these 
patients  by  applying  either  the  continuous  or  the 
faradic  current  according  to  Duchenne's  method 
(one  of  the  poles  being  placed  in  the  rectum,  the 
other  applied  over  the  bulb  of  the  urethra).  It 


366  NEURASTHENIA. 

must  not  be  forgotten  that  it  is  sometimes 
imperatively  necessary  to  restore  the  patient's 
confidence  in  himself,  since  the  despair  into 
which  this  functional  incapacity  plunges  him  may 
lead  to  suicide. 

When  the  patient  is  reassured,  when  state- 
ments and  procedures,  which  must  evidently  vary 
with  each  particular  case,  have  caused  the  con- 
viction to  spring  up  in  his  mind  that  his  affection 
is  not  serious  but  is  perfectly  curable,  he  is 
thenceforward  ready  to  follow  and  to  benefit  by 
the  local  treatment  that  must  then  be  prescribed 
to  him. 

In  order  to  combat  the  symptoms  of  excitement 
that  are  generally  observed  in  the  first  period  of 
genital  neurasthenia,  such  as  frequent  erections, 
nocturnal  pollutions,  etc.,  it  is  necessary  first  of 
all  to  draw  up  for  the  patient  a  set  of  suitable 
hygienic  rules.  He  must  of  course  give  up  his 
habits  of  masturbation,  and  avoid  company  and 
contacts  that  are  liable  to  give  rise  to  erotic 
thoughts  and  keep  up  the  genital  excitement. 
Riding,  excessive  food,  rich  dishes,  spirits  and 
coffee  in  excessive  quantities,  staying  too  long  in 
bed,  must  all  be  forbidden  him,  and  constipation 
must  be  carefully  treated.  Continence  should 
not  be  absolute,  but  sexual  intercourse  is  only  to 
be  permitted  at  long  intervals. 

Among  the  hydrotherapeutic  measures  that  are 
suited  for  calming  spinal  excitability,  we  may 


GENITAL   NEURASTHENIA.         367 

make  use  of  the  warm  douche  at  96°  or  97°  F., 
applied  to  the  whole  body,  especially  to  the  verte- 
bral column,  sitz  baths,  or  prolonged  warm  baths, 
or  ice-bags  applied  to  the  dorso-lumbar  spine. 

Hydrotherapy  again  forms  the  principal  local 
treatment  of  spermatorrhoea  and  of  true  impo- 
tence due  to  atony  of  the  nerve  centres  and 
muscles  concerned  in  erection  and  emission. 

When  one  has  to  deal  with  very  sensitive 
subjects  who  complain  of  pains  or  hyperaesthesiae 
localised  in  the  genital  organs,  one  must  proceed 
with  prudence  in  applying  hydrotherapeutic 
measures  locally.  Sitz  baths  with  still  water  are 
to  be  administered,  first  temperate,  then  cool, 
and  finally  cold.  Thus  one  will  arrive  progres- 
sively at  the  use  of  cold  baths  with  jets  of  water 
(perineal  douches  or  douches  localised  to  the 
region  of  the  genito-urinary  centre  in  the  spine). 
Beard  recommends  cold  enemata. 

Winternitz  has  recommended  the  use  of  the 
psycrofore  in  the  treatment  of  spermatorrhoea  and 
atony  of  the  genital  organs.  This  is  a  sort  of 
metallic  catheter  with  a  double  channel,  which 
enables  the  prostatic  portion  of  the  urethra  to  be 
subjected  to  the  local  action  of  cold.  This  catheter 
is  closed  at  the  urethral  extremity  and  bifurcated 
at  the  other.  When  it  is  placed  in  position,  a 
current  of  water  is  made  to  circulate  through  it 
at  a  temperature  of  65°  F.,  lowered  steadily  to 
55°  or  50°  F.  The  irrigation  lasts  from  eight  to 


368  NEURASTHENIA. 

twelve  minutes.  The  first  applications  are  badly 
borne  in  general,  but  tolerance  is  soon  established, 
and  this  mode  of  treatment  frequently  produces 
excellent  results. 

In  the  treatment  of  these  cases  of  genital 
atony,  one  may  also  apply  local  galvanisation 
according  to  the  method  of  Benedikt  and  Schultz. 
A  weak  current  is  used  ;  the  positive  pole  is  held 
over  the  upper  lumbar  vertebrae,  and  the  negative 
is  moved  over  the  perineum,  the  spermatic  cords, 
and  the  penis  in  succession.  The  application  is 
continued  for  from  three  to  four  minutes  and  is 
repeated  every  day  or  every  second  day.  Fara- 
disation seems  more  efficacious ;  all  the  accessible 
muscles  of  the  perineum  are  faradised  in  succes- 
sion, and  especially  the  bulbo-cavernosi,  or  else 
one  of  the  poles  is  placed  in  the  rectum  and  the 
other  on  the  perineum  and  the  root  of  the  penis. 

The  action  of  these  local  methods  of  treatment 
must  of  course  be  seconded  by  putting  into 
operation  the  various  hygienic  measures  that  are 
required  in  the  general  treatment  of  neurasthenic 
conditions. 

As  to  pure  traumatic  neurasthenia  it  does  not 
appear  to  us  to  offer  any  special  therapeutic 
indications.  The  treatment  of  this  etiological 
variety  of  nervous  exhaustion  differs  in  no 
essential  point  from  that  of  cerebro-spinal 
neurasthenia  in  general. 


INDEX    OF    SUBJECTS. 


ABDOMEN ;  in  enteroptosis, 
285 ;  in  gastrointestinal 
atony,  57, 58, 236 ;  in  muco- 
membranous  colitis,  294, 
295,  305 ;  in  Reichmann's 
disease,  67. 

Abdominal  discomfort,  265. 
„          douche,  320. 
„          pack,  321. 

Abnormalities  of  character,  16, 
91,  160,  166. 

Aboulia,  4,  70,  95,  104,  119, 
342,  346,  347,  348,  359.  See 
also  Will,  enfeeblement  of. 

Absence  of  mind,  71. 

Accidents ;  personal,  102 ; 
railway,  35,  101,  102. 

Accommodation,  weakness  of 
muscles  of,  86. 

Aching,  sensation  of,  in  spine, 
47. 

Achlorhydria,  61,  62, 247, 248, 
253. 

Acid,  hydrochloric,  see  Hy- 
drochloric acid. 

Acidity  of  gastric  juice  in 
dyspepsia  of  N.,  61,  62,  63. 

Acids,  fatty,  produced  by  fer- 
mentation of  carbohydrates, 
295. 

Acids,  organic,  in  dyspepsia  of 
N.,  61,  62. 

Activity,  diminution  in,  48, 
95,  96. 

Acute  N.,  91,  108. 

Acute  stage  of  N.,  91. 

Neurasthenia. 


Adversity,  as  a  cause  of  N., 

11  (note).  See  also  Reverses 

of  fortune. 
Affection,  thwarted,  a  cause  of 

N.,  25  ;   of  the  neurosis  of 

anxiety,  124. 
Affection  of  parents,  should  be 

a  reward,  165. 

Age,   distribution  of  N.   ac- 
cording to,  9,  10. 
Agoraphobia,  74,  206. 
Agriculturalists,  N.,  in,  11. 
Air,  fresh,  effects  of,  328. 
Albumen,  proportion  of  animal 

in  diet,  258.     See  also  Pro- 

teids. 
Albuminoid  products  of  faulty 

digestion  as  a  cause  of  N., 

129. 
Albuminuria,    transient,    88, 

89  (note). 
Alcohol,  in  diet,  158, 214,  235, 

359,  366.    See  also  Wine 

and  Beer. 
Alcohol,  abuse  of ;  a  cause  of 

N.,  30,  31,  33  (note),  36; 

complicating  N.,  xvii,  186; 

caused  by   N.,   235,   242, 

243. 

Alcoholism  in  parents,  a  pre- 
disposing cause,  16. 
Alet  water,  263,  306. 
Alkalies,  250,  254. 
Aloes,  268,  279,  359. 
Alps  of  Savoy  and  Dauphin^, 

331,338. 

24 


370 


INDEX    OF    SUBJECTS. 


Altitudes;  of  6,500  feet  and 
upwards,  325,  326,  327  ;  of 
3000  feet  and  upwards,  327, 
328,  331 ;  of  1300  to  3000 
feet,  327,  331. 

Ambition,  an  exciting  cause 
of  N.,  9,  36. 

America,  N.  in,  7,  8,  41. 

Amnesia,  in  N.,  70,  71,  72. 

Amyosthenia,  see  Asthenia, 
muscular. 

Anaemia ;  a  supposed  cause  of 
N.,  4,  5, 129;  in  N.,  59,  212, 
288,  239,  326,  330,  331,  346, 
347,  349,  359 ;  of  skin  and 
mucosae  (pseudo-anaemia), 
80  and  note. 

Anaesthesia,  not  found  in  pure 
N.,  79. 

Anderson's  pills,  279. 

Anger,  160. 

Angina  pectoris,  83, 84, 85, 92. 

Angoissc,  defined,  124  (note). 

Animal  diet,  232,  244. 

Anorexia,  56,  67,  96, 186, 297, 
302,  305,  347,  357. 

Anthropophobia,  74. 

Antiseptics,  intestinal,  298, 
299,  300. 

Anxiete,  defined,  124  (note). 

Anxiety  ;  a  cause  of  N.,  20, 
25,  95 ;  a  symptom,  42,  73, 
74,  186,  334 ;  improved  by 
psychotherapy,  200. 

Anxiety ;  neurosis  of,  xxii, 
123, 124. 

Anxiety;  precordial,  92,  93, 
99,  116  (note). 

Apathy,  191. 

Aperients;  excessive  use  of 
by  neurasthenics,  267  ;  bad 
effects  of,  268 ;  to  be  used 
as  little  as  possible,  268; 
those  to  be  used,  277-280 ; 
rules  in  using,  280,  281; 
in  enteroptosis,  290,  291 ;  in 


muco-membranous  colitis, 
298,  299,  300;  in  N.  of 
women,  359. 

Appetite,  56,  65,  67,  96,  186, 
235,  281,  297,  302, 305, 328, 
347,  357. 

Apples,  242,  259. 

Archaus,  126. 

Argyll- Robertson's  sign,  111, 
112,  206. 

Aromatic  products  of  proteid 
fermentation,  295. 

Aros,  325. 

Arrowroot,  303. 

Arterial  tension,  high,  some- 
times accompanied  by  neur- 
astheniform  symptoms,  113. 

Arterial  tension,  low,  in  N., 
83,  89  (note).  See  also 
Vasomotor  system. 

Arteries,  spasm  and  relaxation 
of.  See  Vasomotor  system. 

Arterio-sclerosis  and  N.,  xx. 

Arthritic  auto-intoxication, 
sometimes  accompanied  by 
neurastheniform  symptoms, 
113. 

Arthritic  diathesis,  its  con- 
nection with  neuropathic 
states,  xvii,  13,  256. 

Arthritic  diseases ;  in  family 
history,  13,  66,  158;  ac- 
companying N.,  xx. 

Arthritic  patients ;  simple  hy- 
perchlorhydria  in,  66;  hy- 
drotherapeutic  treatment  of, 
315,  316,  317;  dietetic 
treatment  of,  158,  256; 
maritime  climates  bad  for, 
334. 

Artichokes,  262. 

Artists,  N.  in,  11. 

Asparagus,  218,  241  and  note, 
259,  262. 

Asthenia,  muscular  (or  neuro- 
muscular);  a  fundamental 


INDEX    OF    SUBJECTS. 


371 


symptom,  3, 42, 44, 115, 117, 
180  ;  characters  of,  48-52  ; 
often  psychical,  52,  70 ;  per- 
haps only  a  dysaesthesia  of 
the  locomotor  system,  79 ; 
in  hemi-N.,  92  ;  in  cerebro- 
spinal  N.,  93,  94 ;  in  N.  of 
women,  95 ;  in  genital  N., 
99;  in  traumatic  N.,  103; 
in  transient  conditions  re- 
sembling N.,  138 ;  a  cause 
of  tachycardia,  82 ;  may  be 
lessened  or  dispelled  by 
psychical  treatment,  138;  as 
an  indication  in  climatic 
treatment,  329,  331,  334, 
336 ;  in  treatment  by  exer- 
cise, 342. 

Asthenia,  nervous,  see  Neur- 
asthenia. 

Asthenic,  the,  115. 

Asthenopia,  neurasthenic,  86, 
93,  103. 

Ataxy,  Locomotor,  see  Loco- 
motor  ataxy. 

Athletic  sports,  343. 

Atlantic  coast  of  France,  333. 

Atmospheric  changes,  sensi- 
tiveness to,  78,  322. 

Atony,  gastric,  304 ;  congenital 
(a  supposed  cause  of  N.), 
127. 

Atony,  gastro-intestinal ;  a 
leading  symptom,  3,  44,  55, 
115,  117,  180 ;  more  often 
the  effect  than  the  cause,  5 ; 
characters  of  slight  form,  56- 

59,  236 ;  of  severe  form,  59, 

60,  245  ;  in  gastric  N.,  92 ; 
in  cerebro-spinal  N.,  93  ;  in 
traumatic  N.,  103,  104  ;   in 
transient  conditions  resemb- 
ling    N.,      138;      dietetic 
treatment   of   slight    form, 
237-245,  260-264 ;  of  severe 
form,    245-249 ;    medicinal 


treatment,  250,  277 ; 
electrical  treatment,  251, 
252  ;  washing  out  stomach 
in,  252;  in  N.  with  gout, 
256  ;  not  the  sole  cause  of 
constipation  in  N.,  266; 
symptoms  due  to,  not  easy 
to  differentiate  from  those 
due  to  enteroptosis,  288 ; 
hy  drotherapeutic  treatment, 
320 ;  climatic  treatment, 
329,  330,  334,  335  (note) ; 
a  centra-indication  to 
travelling,  336  ; — and  Weir 
Mitchell's  treatment,  342, 
353,  357;  aggravated  by 
immobility,  342,  353. 

Atony,  genital,  365,  367,  368. 

Atrabilis,  126. 

Atrophy,  muscular,  49,  50. 

Atrophy,  Progressive  muscu- 
lar, 77. 

Attachments,  laxity  of,  xxii. 

Attention,  power  of,  dimin- 
ished, 22,  70,  71,  89  (note), 
103. 

Auditory  hyperaesthesia  and 
paraesthesiae,  87. 

Authority  of  parents,  164, 165. 

Auto-intoxication  ;  as  a  cause 
of  N.,xx,  35(note),  127, 128, 
129 ;  caused  by  N.,  xxv ;  in 
muco-membranous  colitis, 
295,  297. 

Auto-suggestion,  115, 118, 138, 
139,  140 ;  therapeutic  ap- 
plication of,  207. 

BACON,  277. 

Back,  Painsin,  see  Rachialgia. 

Ball,  games  of,  157. 

Barometers,  "  veritable  liv- 
ing," 78. 

Bathing,  sea  or  river,  158. 

Baths  ;  hip  or  sitz,  314,  367  ; 
plunge,  315 ;  shower,  see 


372 


INDEX    OF    SUBJECTS. 


Douches ;  temperate,  313, 
315  ;  tepid,  316,  319  ;  half-, 
317,  318  ;  hot,  307 ;  warm, 
367 ;  cold,  310,  367. 

Baumann's  coefficient,  296. 

Beans,  218,  220,  241  and  note, 
259,  262,  263. 

Bed,  hours  of,  247,  366.  See 
also  Sleep. 

Beef,  217,  219,  241,  248,  261, 
306,  360,  361 ;  coefficient  of 
utilisation  of,  219,  220. 

Beef-tea,  358,  361. 

Beer,  235,  242,  260,  263. 

Belladonna,  278,  280,  307. 

Belt,  Gle"nard's,  290. 

Benzonaphthol,  298. 

Betol,  299. 

Bicycling,  157,  344. 

"  Bilious  attacks,"  xxv. 

"  Bird'seye  view"  of  diseases, 
107,  110. 

Bisulphide  of  carbon,  poison- 
ingby,a  cause  of  hystero-N., 
32.  ' 

Bladder,  pain  in,  in  muco- 
membranous  colitis,  294. 

Blenorrhagia,  a  supposed  ex- 
citing cause,  33,  97,  363. 

Blood-pressure,  xxi,  83,  89 
(note),  113. 

Blows  on  head,  may  cause 
traumatic  N.,  102. 

Boarding  schools;  defective 
hygienic  conditions  in,  24, 
25,  148,  149,  150 ;  in  Eng- 
land, xxvii ;  should  a  neu- 
rotic boy  go  to  one  ?  xxvii, 
xxviii. 

Bontius'  pills,  279. 

Books,  choice  of,  important, 
190. 

Borborygmi,  265. 

Bordeaux  wine,  260,  263. 

Borderland  cases,  117. 

Boxing,  155. 


/3-oxybutyric  acid,  xix. 

Bradycardia,  82,  83. 

Brain,  over-pressure  of,  see 
Over-pressure. 

Brain,  supposed  lesions  of,  in 
traumatic  N.,  101. 

Brain- work,  inaptitude  for,  22, 
71,  72,  93,  103,  117. 

Brain  (article  of  food),  262. 

Bread,  217,  219,  220, 239,  241, 
263,  358,  360,  361 ;  whole- 
meal or  Graham's,  220, 277, 
361 ;  bran,  277. 

Breathing,  see  Respiration. 

Breast,  pain  in,  92. 

Bright's  disease  ;  and  N.,  xx, 
33  ;  neurastheniform  sym- 
ptoms in,  xvii. 

Bromides,  359. 

Brooding,  189,  191. 

Burning,  sensations  of;  along 
spine,  47,  94  ;  in  trunk  and 
limbs,  78,  103  ;  in  urethra, 
99 ;  in  abdomen,  294. 

Business  anxieties,  20,  36, 337, 
338. 

Business  man,  case  of  a,  51. 
„       ,  neglect  of,  72,  100. 

Butter,  218,  219,  240,  244, 
248,  260,  261,  262,  277,  303, 
305,  306,  358,  360,  361,  362. 

Butyric  acid,  295. 

CABBAGE,  264. 

Cachexia ;  in  gastro-intestinal 
atony,  59  ;  in  Reichmann's 
disease,  67. 

Caecum,  state  of ;  in  constipa- 
tion of  N.,  266  ;  in  entero- 
ptosis,  285,  286;  in  muco- 
membranous  colitis,  294, 
295. 

Ccecal  sausage,  285,  286. 

Cakes,  262,  263,  264,  305. 

Calf  s  tongue,  262. 

Calomel,  xxvi,  299,  300. 


INDEX    OF    SUBJECTS. 


373 


Calorie,  215,  216,  225,  226 
and  note. 

Camomile,  infusion  of,  248, 
263. 

Cancer,  gastric,  resemblance 
to  cachexia  of,  59,  67  ;  false 
belief  in,  238. 

Cannes,  333. 

Cantani's  dietary,  257. 

Caproic  acid,  295. 

Carabana  water,  268,  299. 

Carbohydrates,  213-222, 225- 
229,  241,  243,  257,  258,  259, 
304  ;  products  of  fermenta- 
tion of,  295.  See  also  Starch 
and  Starchy  Food. 

Carbon  bisulphide,  poisoning 
by,  a  cause  of  hystero-N., 
32. 

Cardiac  innervation,  disorders 
of,  80-83. 

Cardiac  N.,  80,  92. 

Cares,  a  cause  of  N.,  xviii,  9, 
10,  20,  25,  26,  36,  175,  180. 

Carrots,  259,  262. 

Cascara  Sagrada,  268,  280 
(note). 

Cascarine,  279,  280  and  note. 

Casein,  220,  225. 

Casque  neurasthenique,  45. 

Castor  oil,  268,  279,  299,  300  ; 
suppositories  of,  276. 

Catastrophes,  public,  the  usual 
cause  of  traumatic  N.,  35, 
102. 

Causes  of  N. ;  general,  xviii, 
xix,  xx,  6-11 ;  special,  12- 
16,  126-140;  exciting,  17- 
37 ;  almost  always  multiple, 
37  ;  the  part  played  by  each 
must  be  ascertained  pre- 
cisely in  each  case,  37,  176, 
204. 

Cauliflowers,  259,  262,  264. 

Celery,  262. 

Cereals,  232,  233,  241. 


Cerebellar  vertigo,  sometimes 
simulated,  77. 

Cerebral  depression,  see  De- 
pression. 

Cerebral  derangement,  in  gen- 
ital N.,  98. 

Cerebral  N.,  xxvi,  93,  130; 
points  in  treatment  of,  189, 
330,  336,  337,  338,  342,  362. 

Cerebral  over-pressure,  see 
Over-pressure. 

Cerebral  tumours,  diagnosis 
from  N.,  113. 

Cerebrasthenia,  see  Cerebral 
N. 

Cerebrin,  211. 

Cerebro-cardiac  neuropathy, 
vii,  92. 

Cerebro-spinal  fluid,  lympho- 
cytosis  of,  absent  in  N., 
present  in  general  paralysis 
and  locomotor  ataxy,  112. 

Cerebro-spinal  N.,  93,  330, 
342. 

Certainty,  loss  of  feeling  of, 
in  the  maladie  du  doutc,  116. 

Chalk,  255. 

Champagne,  359. 

Character,  abnormalities  of, 
16,  91,  160,  166. 

Character,  altered  in  general 
paralysis,  112. 

Chastisement  of  children,  165, 
166. 

Chatel-Guyon,  301. 

Cheese,  218,  219,  248,  262, 
264,  306. 

Chicken,  217,  262. 

Chicory,  262. 

Chilblains  and  N.,  xx. 

Child-bearing,  frequent,  an 
exciting  cause  of  N.,  36 
(note) ;  of  enteroptosis,  285. 

Children;  N.  rare  in,  9; 
and  over-pressure,  21-24 ; 
death  of,  a  cause  of  N.,  26  ; 


374 


INDEX    OF    SUBJECTS. 


education  of  those  with 
nervous  predisposition,  141- 
169  ;  mental  state  like  that 
of  hypnotised  subjects,  160; 
very  suggestible,  160,  161 ; 
chastisement  of,  165,  166. 

Chloral,  359. 

Chloralism,  186. 

Cider,  254,  260. 

Circular  insanity,  108,  109. 

Circulation  ;  disordered  in  N., 
2;  disorders  of,  72,  80-85, 
133,  134 ;  of  encephalon, 
more  strongly  affected  by 
emotions  than  by  intellec- 
tual work,  19,  20;  differ- 
ently affected  in  neuras- 
thenics and  in  normal  sub- 
jects by  intellectual  Avork, 
133,  134  ;  effects  on,  of 
tobacco,  281 ;  of  climate, 
324,  325,  326,  328,  330,  331, 
334  ;  of  exercise,  active  and 
passive,  339,  341,  342,  344; 
of  immobility,  342,  353  ;  of 
massage,  341,  342,  353  ;  of 
faradisation,  342,  355. 

Classes,  social,  N.  in  different, 
11  and  note,  20. 

Classification  of  diseases,  im- 
portance "of,  109. 

Claustrophobia,  74,  206. 

Clergy,  N.  in,  11,  170  (note). 

Clerks,  N.  in,  11. 

Climatic  influences,  sensitive- 
ness to,  78,  322. 

Climates,  lowland,  332,  333. 

Climates,  maritime,  333,  334, 
335. 

Climates,  mountain  ;  season 
for,  323 ;  physiological 
effects  of,  323-328  ;  indica- 
tions, 327, 328, 330;  counter- 
indications,  326,  327,  330, 
331 ;  requisites  of  resorts  in, 
327,  331. 


Climates,  relaxing,  an  excit- 
ing cause  of  N.,  35  (note). 
Climates,      temperate,      suit 

neurasthenics  best,  322. 
Climates,   value   of    suitable, 

183. 

Clitoris,  pain  in,  92. 
Cocaine,  use  of,  a  cause  of  N., 

31. 
Cocoa,  240,  260, 263,  306,  360, 

361. 

Coccyx,  pain  in,  92. 
Codeine,  307. 
Cod-liver  oil,  244,  358. 
Coefficient,  Baumann's,  296. 
Coefficient ;    of  utilisation  of 

food,  219, 220;  nitrogenous, 

222,  223. 

Coefficients,  method  of,  296. 
Coffee,  235,  236,  239,  240,  243, 

253,   260,    263,    277,    305, 

366. 

Cold,  sensations  of,  in  trau- 
matic N.,  103. 
Cold,  sensitiveness  to,  40,  78, 

297,  322. 
Cold-water     cure,     308-321 ; 

psychical  action  of,  188. 
Coldness  of  segments  of  body, 

84. 
Colic ;  in  enteroptosis,  289  ;  in 

muco-membranous     colitis, 

294. 

Colic  cord,  276,  285,  286. 
Colitis,  acute,  292. 
Colitis,      muco-membranous, 

58,   275,   291-307;    causes 

of,  292 ;  appearance  of  faeces 

in,  292,  293 ;  symptoms  of, 

294,  295,297;  pain  in,  294; 

state  of  intestines  in,  295 ; 

auto-intoxication   in,    295  ; 

bacterial  infection  in,  295  ; 

mental    results    of,     307; 

treatment      of,      298-307 ; 

watering  places  of  service 


INDEX    OF    SUBJECTS. 


375 


in,  301 ;  diet  in,  301-307  ; 
treatment  of  pain  in,  307. 

Colon ;  contraction  of,  in 
spasmodic  constipation, 266, 
276 ;  in  enteroptosis,  285, 
286,  287  ;  pain  in,  in  muco- 
membranous  colitis,  294. 

Common  sensation,  see  Sen- 
sations, organic. 

Companions,  choice  of,  im- 
portant, 191,  192. 

Competitions,  a  cause  of  N., 
18,  20,  24. 

Compound  liquorice  powder, 
279. 

Compresses ;  cold,  in  treat- 
ment of  constipation,  271 ; 
hot,  iced,  or  of  chloroform, 
in  treatment  of  pain  in  muco- 
membranous  colitis,  307. 

Condiments,  242,  248,  253. 

Confidence  in  self,  71,  162, 
164,  182,  189,  344. 

Confined  life,  evil  effects  of, 
25,  95,  149,  150. 

Congestion  ;  of  skin  and 
mucosae,  80,  85  ;  of  internal 
organs,  80  (note),  85. 

Conjunctivas,  injection  of,  86. 

Connective  tissue,  hyperplasia 
of,  xxii. 

Constipation ;  xxv,  58,  96, 
264,  265,  266,  267,  335 
(note),  353  ;  treatment  of, 
264  seqq.,  320, 353,  359,  366; 
spasmodic,  266,  272,  273, 
275,  276,  278 ;  atonic,  266, 
272,  273,  275,  276  ;  in  en- 
teroptosis, 290,  291 ;  a 
cause  of  muco-membranous 
colitis,  291,  292,  298,  301. 

Contractions,  fibrillar,  of 
muscles,  77. 

Contractures,  functional,  77. 

Convalescents,  treatment  of, 
330,  342,  356. 


Conversations,  long,  when  not 
permissible,  190. 

Convulsions,  infantile,  history 
of,  98. 

Co-ordination,  impaired,  77 
(note). 

Corsets  ;  a  cause  of  enterop- 
tosis, 283,  285,  292;  of 
muco-membranous  colitis, 
292 ;  special,  in  treatment 
of  enteroptosis,  289. 

Country  life;  for  children,  148, 
152  ;  in  N.,  183,  184,  185, 
189,  332 ;  symptoms  chiefly 
benefited  by,  333. 

Courage ;  loss  of,  182 ;  in- 
creased by  psychotherapy, 
202. 

Court-bouillon,  261  and  note, 
262. 

Crackings  at  back  of  neck,  46. 

Cramp,  abdominal,  65,  294 ; 
muscular,  77. 

Cramp,  Writer's,  77. 

Cranium  ;  feeling  of  empti- 
ness in,  46 ;  of  floating 
bodies  in,  46. 

Crayfish,  264. 

Cream,  244,  261,  360. 

Creatinine,  223  (note). 

Croquet,  344. 

Cucumbers,  241,  264. 

Cultivated  classes,  liable  to 
N.,  11,  20. 

Cycling,  157,  344. 

DAMP  PACK,  the,  319, 320. 

Dauphine,  subalpine  resorts 
in,  331,  338. 

Day-dreaming,  191. 

Death ;  of  children,  a  cause  of 
N.,  26 ;  said  to  occur  some- 
times in  acute  N.,  91 ;  and 
in  neurasthenic  tachycardia, 
82. 

Debility,    great ;     a   contra- 


376 


INDEX    OF    SUBJECTS. 


indication  to  high  altitudes, 
331 ;  to  travelling,  336 ;  to 
active  movements,  340.  See 
also  Asthenia. 

Debility,congenital,of  nervous 
system,  xv,  xvi,  98. 

Defective  education,  a  cause 
of  N.,  16. 

Defective  physical  conditions, 
a  cause  of  N.,  20. 

Definition  of  N.,  xviii,  1,  2. 

Degeneracy ;  often  associated 
with  hereditary  N.,  91 ; 
with  genital  N.,  98  ;  its  re- 
lations to  N.  generally,  xviii 
seqq. ;  to  the  maladie  du  doutc, 
xxiii,  117. 

Delusional  insanity,  100  and 
note,  137. 

Delusions  in  hypochondriasis 
major,  123. 

Delusions  of  persecution, 
patients  with,  100  and  note, 
137. 

Denutrition,  211. 

Depressed  neurasthenics,  39, 
40. 

Depressing  emotions  ;  an  im- 
portant cause  of  N.,  19,  25, 
26,  33,  36,  131,  159,  180, 
181;  acauseofReichmann's 
disease,  66. 

Depression  of  nerve  strength, 
1,2. 

Depression  cerebral ;  a  funda- 
mental symptom,  44,  181 ; 
characters  of,  69-74  ;  per- 
haps sometimes  duetovaso- 
motor  disorders,  85  ;  aggra- 
vated by  neurasthenic  as- 
thenopia,  86  ;  in  cases  with 
tachycardia,  82  ;  in  gastro- 
intestinal atony,  59,  131, 
238,  240  ;  in  badly  trained 
children,  167  ;  in  traumatic 
N.,  103,  104;  in  N.  of 


women,  95,  346 ;  in  genital 
N.,  100,  364  ;  treatment  of, 
74,  197,  334;  melancholic 
depression,  115,  119. 

Depression,  periodic,  108, 109. 

Dessert,  261,  262,  263,  305. 

Despondency,  see  Depression. 

Detonations,  subjective 

sounds  resembling,  87. 

Development,  imperfect,  xx 
(note),  98. 

Diabetes,  xix,  xx  ;  in  family 
history,  13. 

Diagnosis,  need  of  a  precise, 
xxiii,  106, 109,  113,  125. 

Diarrhrea,  85,  265,  292,  305. 

Diet ;  in  N.  generally,  xi,  158, 
179,  209, 233 ;  triple  aim  of, 
209 ;  as  a  reconstituent  of 
nervous  energy,  210  seqq., 
239  ;  for  rest,  214,  216,  227, 
228, 229  ;  for  work,  214,  216, 
228 ;  for  women,  216 ;  com- 
position of  principal  articles 
of,  217,  218;  milk-,  224, 
225,  226,  228,  231,  244, 
257 ;  lacto-farinaceous-,305, 
306 ;  meat-,  231,  232,  244  ; 
vegetables  in,  232  ;  in  gas- 
tric disorders,  235  seqq. ; 
in  slight  gastric  atony, 
236-245,260-264;  in  severe 
form,  245,  247,  248,  249; 
in  hyperchlorhydria,  253, 
254 ;  in  N.  associated  with 
gout,  256-260  ;  in  constipa- 
tion, 277 ;  in  muco-mem- 
branous  enteritis  (to  disin- 
fect intestine),  298,  301- 
306;  in  genital  N.,  366; 
should  be  mixed,  240,  243, 
247,  249,  254,  258  ;  should 
be  varied,  240,  247 ;  diets 
aiming  at  fattening,  222, 
249,  348 ;  exclusive  diets 
undesirable,  243,  249,  257 ; 


INDEX    OF    SUBJECTS. 


377 


starvation  diets  undesir- 
able, 257  ;  Binswanger's, 
360,  361,  362;  Cantani's, 
257  ;  Leyden's,  360  ;  Weir 
Mitchell's,  249,  357,  358, 
359. 

Digestion,  disorders  of,  see 
Dyspepsia  and  Atony,  gas- 
tro-intestinal. 

Dilatation  of  Stomach,  see 
Stomach. 

Disappointments,  a  cause  of 
N.,  25,  180. 

Discipline  of  treatment,  185, 
188. 

Discomfort  in  spine,  sensa- 
tion of,  47. 

Discouragement,  95,  181. 

Diseases,  infective  and  or- 
ganic ;  as  a  cause  of  N., 
32,  33,  34,  36,  175;  in 
parents,  a  cause  of  N.,  15, 
16. 

Disintegration  of  personality, 
and  N.,  xxiv. 

Disquiet,  a  cause  of  N.,  20,  25. 

Disseminated  sclerosis,  34,  52, 
180. 

Diuresis  and  elimination  of 
uric  acid,  259. 

Doctor,  see  Physician  and 
Medical  men. 

Doubt-fears,  122. 

Doubts,  morbid,  70,  91,  98, 
114,  115-118,  121. 

Douches  ;  cold,  158,  309,  310, 
311,  313,  314,  319;  cool, 
313;  hot,  313,  314;  luke- 
warm, 313 ;  warm,  313,  316, 

319,  321,  367  ;  Scotch,  313, 
316,317,319,321;  localised, 

320,  321,  367;   abdominal, 
320  ;     dorso-lumbar,    320  ; 
alternating,  320 ;   perineal, 
367 ;       to      genito-urinary 
centre  in  spine,  367. 


Doughy  foods,  259,  261,  263, 
265,  303. 

Doute,  maladie  dtt,  xxiii,  116, 
117, 118,  121,  122,  179. 

Dragging,  sensation  of,  in 
spine,  47. 

Drawing,  191. 

Dreams,  53,  54,  103. 

Drinking  between  meals,  247. 

Drugs ;  often  useless  and 
sometimes  harmful,  xi,  xxv, 
176  ;  less  useful  than  other 
modes  of  treatment,  176, 
348 ;  in  severe  gastro-in- 
testinal  atony,  250  ;  in  con- 
stipation, 268, 277-281,  290, 
291 ;  in  hyperchlorhydria, 
254,  255 ;  in  enteroptosis, 
290,  291 ;  in  muco-mem- 
branous  colitis,  298,  299, 
300,  307;  in  Weir  Mitchell's 
treatment,  359. 

Dysaesthesiae,  79 ;  vaso-motor 
origin  of,  134. 

Dyspepsia  ;  a  supposed  cause 
of  N.,  4,  35,  68,  127,  129- 
132  ;  of  neuropathic  states 
in  general,  127,  283;  a 
fundamental  symptom  of 
N.,  3,  39,  44,  72,  111; 
sometimes  absent,  235 ; 
characters  of,  54-69,  235- 
238,  245;  necessity  of 
noting  its  character  with 
care,  69 ;  from  the  use  of 
toxic  substances,  31 ;  an 
indirect  cause  of  tachy- 
cardia, 82 ;  in  spinal  N., 
94 ;  in  genital  N.,  99 ;  in 
traumatic  N.,  103,  104  ;  in 
N.  of  women,  346,  347  ;  in 
muco-membranous  colitis, 
295,  301 ;  relation  of  to  en- 
teroptosis, 283,  284,  289; 
effect  of  different  climates 
on,  329,  330,  331,  334; 


378 


INDEX    OF    SUBJECTS. 


effect  of  massage  and 
faradisation  on,  355  ; — and 
Weir  Mitchell's  dietary, 
357. 

EARS ;  noises  in,  47, 87, 103 ; 
malformations  of,  98. 

Earthquakes,  a  cause  of  trau- 
matic N.,  35,  102. 

Eccentricity,  in  early  history 
of  hereditary  neurasthenics, 
91. 

Economical  and  political  con- 
ditions, abrupt  change  of, 
the  cause  of  the  increase  in 
N.,  8,  9. 

Eczema,  158. 

Education ;  bad,  a  cause  of 
N.,  16,  36  ;  insufficient 
physical,  16  ;  of  children 
with  neurotic  heredity,  142- 
170  (physical,  144,  145, 
146-158;  moral,  144,  145, 
159-170 ;  intellectual,  145); 
different  views  as  to  power 
of,  142-144 ;  may  substitute 
acquired  for  innate  habits, 
144  ;  triple  aim  of,  144  ; 
varying  ideals  of,  146,  147 ; 
family  system  of,  151,  152. 

Eels,  264. 

Effleurage,  272. 

Effort,  mental,  incapacity  for, 
22,  71,  72,  93,  104. 

Eggs,  218,  232,  240,  241,  254, 
257,  260,  261,  262,  263,  303, 
304,  306,  361,  362. 

Ego,  weakening  of,  72. 

Electricity;  not  a  panacea, 
179 ;  psychical  action  of, 
183,  184,  187,  188,  199; 
static,  187  ;  galvanic,  187, 
251,  365,  368 ;  faradic,  187, 
251,  342,  355,  365,  368 ;  in 
gastric  atony,  251,  252  ;  in 
constipation,  273  ;  in  Weir 


Mitchell's  treatment,  342, 
348,  355,  357 ;  in  genital 
atony,  364,  365,  368. 

Emaciation,  59,  67,  96,  212, 
238,  245,  249,  340,  346, 
347,  359. 

Emission,  centre  for,  98,  363, 
367. 

Emissions,  88,  99,  366. 

Emotionalism;  a  symptom, 42, 
71,  93, 103, 180;  congenital, 
167  ;  benefited  by  country 
life,  333. 

Emotional  side,  most  neuras- 
thenics affected  on  the,  26. 

Emotional  states  ;  distressing 
in  N.,  71,  79  ;  contagious- 
ness of,  168. 

Emotional  tendencies  in  family 
history,  15. 

Emotions  ;  affect  cerebral  cir- 
culation more  strongly  than 
does  intellectual  work,  19, 
20 ;  depressing,  an  impor- 
tant cause  of  N.,  xviii,  19, 
25,  26,  33,  36,  54,  159,  180, 
181;  of  Reichmann's  disease, 
66  ;  sudden  and  violent,  the 
cause  of  traumatic  N.,  34, 
53,  102  ;  a  cause  of  dys- 
pepsia, 59, 130;  disorder  of, 
the  primary  phenomenon  in 
melancholia,  119. 

Emptiness,  feeling  of,  in 
cranium,  46. 

Encouragement,  beneficial 
action  of,  74,  185,  202. 

Enemata  ;  for  thirst,  242  ;  in 
constipation,  269,  270,  273, 
274,  275,  276,  280;  in  muco- 
membranous  colitis,  298, 
300;  in  genital  N.,  367; 
irritating,  a  cause  of  muco- 
membranous  colitis,  292. 

Enervation,  caused  by  sea- 
side, 334. 


INDEX    OF    SUBJECTS. 


379 


Enteric  fever,  as  a  cause  of 
N.,  32. 

Enteritis,  291. 

Entero-colitis,  pseudo-mem- 
branous, see  Colitis,  muco- 
membranous. 

Enteroptosis,  282-291,  298; 
cause  of,  xxii,  283,  284  and 
note,  285 ;  more  frequent 
in  women,  285 ;  signs  of, 
285,  286,  287;  symptoms 
probably  due  to,  in  neuras- 
thenic patients,  288,  289; 
treatment  of,  289,  290,  291 ; 
hampers  movement  of  in- 
testinal contents,  290;  a 
supposed  cause  of  N.,  132, 
283. 

Environment ;  neurasthenics 
much  affected  by,  74,  182, 
322 ;  that  suitable  for 
neurotic  children,  147-152. 

Epigastric  pack,  320,  321. 

Epigastrium,  abnormal  sen- 
sations at,  57,  65,  66,  236  ; 
pulsation  at,  81  (note). 

Epilepsy,  rare  in  the  family 
history,  15. 

Equilibrium,  loss  of,  on  shut- 
ting eyes,  111,  206  and 
note. 

Erection,  centre  for,  98,  363, 
367. 

Erection,  disorders  of,  99. 

Erethism,  see  Excitement. 

Ergographic  investigations, 
49,  50. 

Eructations,  57,  67. 

Erythema,  transient,  85. 

Esteem  shown  in  public,  a 
valuable  form  of  suggestion, 
161. 

Etherism,  186. 

Ethnographic  distribution  of 
N.,  7,8. 

Etiology  of  N.,  6-37, 126-140. 


Euonymin,  279,  280. 

Europe,  N.  in,  7,  8. 

Evian  water,  263,  306. 

Examination  of  a  patient  with 
N.,  38,  39,  42,  43,  113,  200, 
201,  204. 

Examinations,  a  cause  of  N., 
18,  20,  23,  24. 

Excesses,  a  cause  of  N.,  10  ; 
genital,  4,  97,  98,  132,  364; 
of  work,  36, 138 ;  of  eating, 
138. 

Excitability  of  the  senses  and 
appetites,  benefited  by 
country  life,  333. 

Excitement ;  symptoms  of, 
frequent  in  N.,  2;  morbid, 
in  schoolboys,  22  ;  may  be 
a  manifestation  of  nervous 
fatigue,  xvi,  155 ;  genital, 
150, 169 ;  cerebral  or  cardiac, 
a  contra -indication  to  tea, 
coffee  and  tobacco,  243  ;  as 
an  indication  in  climatic 
treatment,  331,  333,  334; 
in  N.  minor,  xvi. 

Exercise ;  insufficient,  25 ; 
necessity  of  regulating  form 
and  amount  of,  340,  343, 
345  ;  physiological  action, 
339 ;  active,  indications  and 
contra-indications,340-342 ; 
passive,  341,  342,  355. 

Exercises,  suitable ;  for 
children,152-158 ;  requisites 
of,  156,  157 ;  for  neuras- 
thenics, 343,  344  ;  in  pure 
cerebrasthenia,  189  ;  Swe- 
dish, 343  ;  in  constipation, 
271. 

Exhaustion  ;  cerebral,  in  N., 
115  ;  on  waking,  128. 

Exophthalmic  goitre,  77,  81. 

Eyeballs  ;  feeling  of  pressure 
on,  46  ;  of  tension  in,  86. 

Eyelids,  slight  oedema  of,  86. 


380 


INDEX    OF    SUBJECTS. 


Extractives  of  meat,  more  or 
less  toxic,  244. 

FACE,  rushes  of  heat  to,  92, 
236,  265. 

Facies ;  of  depressed  neuras- 
thenic, 40  ;  of  lively  neuras- 
thenic, 41 ;  in  severe  form 
of  gastro-intestinal  atony, 
59;  in  Reichmann's  disease, 
67  ;  in  genital  N.,  100  ;  in 
traumatic  N.,  103,  104  ;  in 
muco-membranous  colitis, 
297. 

Faeces,  appearance  of;  in  con- 
stipation, 267 ;  in  spasmodic 
constipation,  276;  in  muco- 
membranous  colitis,  292, 
293,  297. 

Faintness,  feeling  of,  294. 

Falls,  a  cause  of  traumatic 
N.,  102. 

False  ideas;  in  melancholia, 
119;inN.,121,180,181,238. 

Family  system  of  education, 
151. 

Farinaceous  food,  see  Starch 
and  Starchy  food. 

Farinaceous  vegetables,  241. 

Farmers,  N.  in,  11. 

Fatigue ;  characteristics  of, 
xvi;  chronic,  of  nervous 
system,  xvi,  xviii ;  caused 
by  products  of  imperfect 
metabolism,  xix,  xx,  127 ; 
a  fundamental  symptom  of 
N.,  xviii,  48,  111,  115,  117, 
235,  240;  more  lasting  in 
N.  than  in  health  or  mus- 
cular atrophy,  50  ;  of  loco- 
motor  system,  79 ;  rapid, 
94,  95  ;  anatomical  seat  of, 
136,  137;  not  purely  sub- 
jective, 139;  but  largely  so, 
139,  140  ;  loss  of  sense  of, 
xxv. 


Fatigue  products,  as  a  cause 
of  N.,  xx. 

Fatty  acids,  295. 

Fatty  food,  213-222,  225-229  ; 
in  slight  form  of  gastro-in- 
testinal atony,  243,  264  ;  in 
severe  form,  248;  in  hy- 
perchlorhydria,  254 ;  in 
gout,  257,  258 ;  excess  of, 
not  advisable,  244 ;  laxative 
action  of,  277. 

Faults ;  of  parents,  contagious, 
160 ;  should  not  be  sug- 
gested to  children,  162. 

Fears,  morbid,  42,  72,  73,  74, 
182. 

Febrile  attacks,  simulated,  85. 

Feet,  transient  osdema  of,  85. 

Fencing,  153,  154,  155. 

Fencing-master,  case  of,  29, 
30. 

Fermentation  of  chyme,  ab- 
normal ;  in  gastro-intestinal 
atony,  62,  240,  246,  248, 
252,  254,  357 ;  a  supposed 
cause  of  N.,  127  ;  lessened 
by  Hydrochloric  Acid,  250  ; 
in  muco-membranous  coli- 
tis, 295,  303 ;  of  proteids  and 
carbohydrates,  products  of, 
295. 

Fever,  said  to  occur  in  acute 
N.,  91 ;  simulated,  85. 

Fibrillar  contractions,  77. 

Field  of  vision,  narrowing  of, 
86,  87. 

Fingers,  "  dead,"  and  N.,  xx. 

Fish,  217,  220,  241,  257,  261, 
264.  See  also  under  generic 
names. 

Fixed  ideas,  70,  71,  72,  73, 
119,120,121,123,180,357; 
treatment  of,  204,  205,  206. 

Fixity  of  symptoms,  distin- 
guishes N.  from  hysteria, 
&c.,  3. 


INDEX    OF    SUBJECTS. 


381 


Flat-foot,  xxii. 

Flatulence,  265. 

Floating  kidney,  283 ;  two 
varieties,  287 ;  the  patho- 
gnomonic  sign  of,  288. 

Flour,  218,  219,  261. 

Flushing  of  skin,  85. 

Foie  gras,  264. 

Foils,  155. 

Folie  circulaire,  108. 

Folie  du  doute,  xxiii,  116,  117, 
118,  121,  122,  179. 

Food ;  voluntary  restriction 
of,  67,  238,  239,  245,  248, 
249,  346  ;  effect  of,  on  vaso- 
motor  instability,  134 ; 
nitrogenous,  fatty  and  car- 
bohydrate, 214-229,  243, 
253,  254,  257,  258  ;  salts  of, 
222,229-234.  See  also  Diet, 
Proteids,  Fatty  food,  Car- 
bohydrates, and  Starchy 
food. 

Football,  344. 

Forehead,  headache  localised 
in,  46. 

Formication,  103. 

Forms  of  N.,  90-104. 

"  Formula  of  his  bad  instincts, 
The,"  162. 

Fortune,  reverses  of,  a  cause 
of  N.,  9,  26. 

Fowl,  217,  262,  306. 

France ;  N.  in,  7,  8 ;  alpine 
resorts  in,  331 ;  seaside  re- 
sorts in,  333. 

French  beans,  241,  262. 

Fresh  air,  effect  of,  328. 

Friction,  wet,  309. 

Fried  food,  264. 

Friends,  pernicious  influence 
of,  74, 96, 185, 186, 349, 350. 

Fright,  a  cause  of  N.,  33,  34, 
35, 102. 

Frivolity,  a  cause  of  N.,  11 
(note). 


Fruit,  218,  242,  262,  264,  277, 
301,  306,  360,  361,  362. 
See  also  under  generic 
names. 

GAIT  ;  of  depressed  neuras- 
thenic, 40 ;  in  traumatic  N., 
103. 

Game,  217,  262,  264. 

Games ;  most  suitable  form 
of  exercise  for  children,  149, 
157  ;  for  neurasthenics,  343, 
344. 

Gastric  N.,  92. 

Gastric  resonance,  57. 

Gastric  secretion,  disorders 
of,  60-68, 127, 128, 130,  236, 
237,  245,  253,  254,  255. 

Gastric  succussion,  57,  58. 

Gastric  theories  of  etiology, 
126-132. 

Gastritis,  a  supposed  cause  of 
neuropathic  states,  127. 

Gastro-intestinal  disorders ;  a 
supposed  cause  of  N.,  4, 
35,  126-132;  difficulty  of 
treating,  in  N.,  301.  See 
also  Atony,  gastro-in- 
testinal,  and  Constipation. 

Gastroptosis,  283. 

"  General  neuralgia,"  78. 

General  paralysis ;  as  a  cause 
of  N.,  34  ;  diagnosis  of,  from 
N.,  Ill,  112;  cases  with 
neurastheniform  prodrom- 
nal  symptoms,  112. 

Genital  atony,  88,  98,  363, 
365,  367,  368. 

Genital  disorders  and  excesses, 
as  causes  of  N.,  4,  35,  97, 
132,  133. 

Genital  disorders  in  loco- 
motor  ataxy, 111 ;  in  general 
paralysis,  112. 

Genital  excitement,  98,  150, 
169,  363,  366. 


382 


INDEX    OF    SUBJECTS. 


Genital  functions,  disorders  of, 
2,  88 ;  in  genital  N.,  99  ; 
in  traumatic  N.,  104 ; 
treatment  of,  363-368. 

Genital  instincts,  effect  of  con- 
finement on,  150. 

Genital  N.,  87,  93,  97-100 ; 
symptoms  largely  of  mental 
origin,  363;  treatment,  363- 
368. 

Genital  organs,  pains  and  hy- 
peraesthesia  in,  92,  99 ; 
treatment  of,  367. 

Genital  organs,  malformations 
of,  98. 

Genital  theory  of  etiology, 
132,  133. 

Genito-urinary  disorders  in 
N.,  2,  87,  88,  89. 

Genu  valgum,  xxii. 

Germany,  N.  in,  7,  8. 

Gherkins,  259,  263. 

Giddiness,  see  Vertigo. 

Glenard's  belt,  290. 

Glossodynia,  92. 

Gluten,  220. 

Glycerinated  enemata,  274, 
276. 

Glycerine  suppositories,  276. 

Glycosuria  in  traumatic  N., 
104. 

Gonorrhoea,  as  a  cause  of  N., 
33  97 

"  Good  "'  child,  the,  159. 

Gooseberries,  259. 

Gout ;  in  family  history,  13, 
66,  158  ;  as  a  cause  of  N., 
256 ;  dietetic  treatment  of, 
256-260. 

Graham's  bread,  361. 

Grapes,  259, 262, 264, 271, 301. 

Graphic  method,  227,228,229. 

Gravel  in  family  history,  13, 
158. 

Guilt,  false  ideas  of,  in  melan- 
cholia, 119. 


Gymnastics  ;  suitable  and  un- 
suitable forms  of,  for 
children,  152-157  ;  for  neur- 
asthenics, 343,  344 ;  should 
tire  the  muscles  rather  than 
the  nerve  centres,  155, 156 ; 
with  apparatus,  unsuitable, 
155,  156,  343  ;  in  treatment 
of  constipation,  271 ; 
Swedish,  343 ;  Zander's 
mechanical,  343. 

HABITS,  readily  acquired  by 
neurasthenics,  273. 

Habits,  bad ;  correction  of, 
181 ;  of  patients  with  con- 
stipation, 267,  268,  269. 

Haematopoiesis,  328. 

Half-bath,  317,  318. 

Hallucinations  of  half-sleeping 
state,  168. 

Ham,  262,  264,  306. 

Head ;  feeling  of  emptiness 
in,  46,  139;  of  bodies 
floating  inside,  46 ;  blows  on, 
a  cause  of  traumatic  N.,  102. 

Headache ;  a  leading  symp- 
tom, 3,  44,  78,  115,  117, 
212  ;  characters  of,  45,  46, 
47,  139  ;  in  schoolboys,  22  ; 
in  slight  form  of  gastro-in- 
testinal  atony,  56  ;  in  hemi- 
N.,  92 ;  in  cerebro-spinal 
N.,  93  ;  in  genital  N.,  99  ; 
in  traumatic  N.,  103  ;  less 
intense  in  N.  than  in  cere- 
bral tumour,  113;  in  organic 
disease,  113  ;  may  be  due 
to  condition  of  stomach, 
128  ;  in  transient  conditions 
due  to  excess,  138  ;  in  some 
cases  of  muco-membran- 
ous  colitis,  297;  hydro- 
therapeutic  treatment  of, 
319  ;  effect  of  climates  on, 
329,  330,  333. 


INDEX    OF    SUBJECTS. 


383 


Health  resorts ;  in  muco- 
membranous  colitis,  301 ; 
in  N.,  322-338. 

Hearing,  disorders  of,  87. 

Heart ;  disease  of,  as  a  cause 
of  N.,  33  ;  disorders  of,  in 
N.,  81-84 ;  in  cardiac  N., 
80,  92;  in  genital  N.,  99; 
palpitation  of,  in  overworked 
schoolboys,  22;  in  gastro- 
intestinal atony,  57 ;  excite- 
ment and  palpitations,  a 
centra-indication  to  tea, 
coffee  and  tobacco,  243 ; 
disease  of,  sometimes  ac- 
companied by  neurastheni- 
form  symptoms,  113  ;  effect 
on,  of  different  climates, 
324,325,326,328,331,334; 
action  on,  of  massage,  353  ; 
disease  of,  and  N.,  xx ; 
mobile,  xxii. 

Heat ;  sensation  of,  in  spine, 
47  (note) ;  rushes  of,  92, 
236,  265,  297 ;  feeling  of, 
sometimes  caused  by  sea- 
side, 334 ;  sensitiveness  to, 
78, 322 ;  unit  of,  see  Calorie. 

Heaviness;  in  limbs,  48;  in 
body,  139  ;  of  head,  236. 

Hebetude,  103. 

Hemicrania ;  in  family  history, 
15;  in  N.,  xxi,  xxv,  89 
(note). 

Hemi-N.,  92. 

Hemiparesis,  simulation  of, 
92. 

Hepatic  N.,  132. 

Hepatoptosis,  283,  287. 

Hereditary  N.,  14,  66,  91, 
130;  frequently  associated 
with  signs  of  degeneracy,91. 

Heredity ;  as  a  cause  of  N., 
xix,  12-16,  36,  91,  141; 
may  be  no  morbid  heredity, 
17,  36 ;  similar  and  dis- 


similar, 12,  13;  neuro- 
arthritic,  13,  14,  15,  17,  36, 
141,  158  ;  can  its  effects  be 
modified?  142,  143,  144; 
mental  stress  and  neuro- 
pathic heredity,  xviii  (note). 

Herring,  217,  264. 

Hesitancy,  70. 

History,  family  and  personal, 
to  be  carefully  investigated, 
204,  206. 

Honey,  277  ;  honey  enemata, 
275. 

Hors  d'ceuvre,  263. 

Hospital  patients,  cause  of  N. 
in,  26. 

Humidity,  sensitiveness  to,  78. 

Humming  in  ears,  47,  76,  87, 
103. 

Hungarian  wine,  361. 

Hunger,  false  sensations  of  in 
N.,  probably  a  sign  of 
enteroptosis,  288. 

Hunyadi  Janos  water,  268, 
291,  299. 

Hydrochloric  acid,  gastric 
secretion  of,  60-68 ;  simple 
increase  of,  62,  63,  64,  128, 
130,  236,  237,  245,  253, 256 ; 
intermittent  hypersecretion 
of,  66,  255  ;  continuous  hy- 
persecretion of,  67,  255 ; 
deficiency  of,  61,  62,  63,  64, 
127, 128, 130,  245, 247, 250, 
253. 

Hydrochloric  acid,  as  a  drug 
in  gastro-intestinal  atony, 
250. 

Hydrotherapeutics ;  for  child- 
ren with  neurotic  heredity, 
158,  168,  169;  action  of, 
158,  168,  169, 183, 184, 188, 
308 ;  methods  of,  309-318  ; 
all  procedures  not  equally 
applicable,  308  ;  to  be  used 
with  great  prudence,  321 ; 


384 


INDEX    OF    SUBJECTS. 


duration  of  treatment,  311 ; 
frequency  of  application, 
312;  in  arthritic  subjects, 
315,  316,  317  ;  treatment  of 
headache  and  vertigo  by, 

319  ;  of  insomnia,  319 ;   of 
gastro-intestinal  atony,  237, 

320  ;  of  rachialgia  and  pre- 
cordial  pains,  321 ;  of  genital 
N.,  366,  367. 

Hyeres,  333. 

Hygiene ;  bad,  an  exciting 
cause  of  N.,  36;  in  boarding- 
schools,  24,  25 ;  a  wise  regu- 
lation of,  the  best  treatment 
of  N.,  176,  xi,  xxvi ;  moral, 
xi,  177 ;  of  mouth,  247. 

Hygienic  measures,  psychical 
influence  of,  183-192. 

Hyperacidity  of  gastric  juice, 
61,  63,  130.  See  also  Hy- 
perchlorhydria. 

Hyperacousia,  87,  103. 

Hyperaesthesia,  78  ;  of  scalp, 
47,  78  ;  of  skin  over  spine, 
48 ;  of  genito-urinary  or- 
gans, 48,  367 ;  auditory,  87, 
103 ;  vaso-motor  origin  of, 
134  ;  —  and  maritime  cli- 
mates, 334  ; — and  massage, 
355 ; — and  hydrotherapeu- 
tic  measures,  367. 

Hyperchlorhydria ;  simple,  62, 

63,  64,  65,  66, 128, 130,  237, 
245,  256 ;   intermittent,  64, 
66 ;     continuous,    64,    67 ; 
treatment,  253,  254,  255. 

Hypersecretion,    gastric,    62, 

64,  66,  67,  68,  254,  255. 
Hypnotic    "  sleep "    of   pure 

neurasthenics  not  genuine, 

197,  198,  199. 
Hypnotic     suggestion,     196- 

200 ;  dangers  of,  193,  198. 
Hypnotisable ;     all    children 


not,  160;  pure  neurasthenics 
not,  74,  197,  198. 

Hypochlorhydria,  61,  62,  63, 
64,  127,  128,  130,  245,  247, 
250,  253. 

Hypochondriacal  ideas  and 
obsessions,  58,  71,  73,  74, 
88,92,98,100,115,119,121, 
133, 181, 182,  185, 186,  191, 
197,  200,  202,  204,  205,  236, 
364 ;  treatment  of,  197,  204, 
344. 

Hypochondriacal  tendencies 
in  family  history,  15. 

Hypochondriasis,  119-123 ; 
definition,  120 ;  diagnosis 
of,  from  N.,  119,  120,  121 ; 
H.  minor,  xxiii,  116  (note), 
121 ;  H.  major,  xxiii,  121, 
123 ;  fixed  hypochondriacal 
phobias,  121,  122 ;  H.  mi- 
nor in  N.,  73,  74;  some- 
times absent  from  N.,  xxvii ; 
though  rarely,  73 ;  increased 
by  action  of  friends,  74  ;  due 
to  disorder  of  common 
sensation,  80 ;  difference 
between  neurasthenic  and 
insane  H.  (H.  minor  and 
H.  major),  73,  123. 

Hysteria ;  a  psychical  disease, 
3 ;  symptoms  not  so  fixed  as 
in  N.,  3  ;  personality  more 
profoundly  altered  than  in 
N.,  198;  rare  in  family 
history  of  N.,  15;  some- 
times associated  with  N., 
32,  53,  77,  78, 100, 101, 115, 
179 ;  a  necessary  condition 
for  hypnotism,  197,  198; 
treatment  of,  by  suggestion, 
118  ;  a  centra-indication  to 
maritime  climates,  334. 

Hystero-N.,  32,  78,  115,  198  ; 
traumatic,  53,  100. 


INDEX    OF    SUBJECTS. 


385 


ICE-BAGS  to  dorso-lumbar 
spine,  367. 

Ichthyol,  xxvi,  300. 

Ideal  usually  set  before  chil- 
dren, the,  159. 

Ideas ;  false,  in  melancholia, 
119  ;  false,  in  N.,  121 ;  fixed, 
see  Fixed  ideas ;  hypochon- 
driacal,  see  Hypochondria- 
cal  ideas  ;  melancholy,  181. 

Idleness,  a  cause  of  N.,  11 
(note),  28. 

Immobility,  muscular,  evil 
effects  of,  340,  342,  353. 

Impotence,  88,  99,  104,  111, 
364,  365;  treatment,  366, 
367,  368. 

Impressionability  of  neuras- 
thenics, 71,  182. 

Impulses,  morbid,  91,  160; 
treatment,  164,  169. 

Incompleteness,  moral,  117. 

Incontinence  of  urine ;  history 
of,  98  ;  in  locomotor  ataxy, 
111. 

^coordination,  xvi,  77  (note). 

Indol,  295. 

Infantile  convulsions,  history 
of,  98. 

Infective  disease ;  in  the  par- 
ents, a  predisposing  cause, 
15 ;  as  an  exciting  cause, 
32,  33,  34. 

Influenza ;  as  a  cause  of  N., 
32, 33 ;  misuse  of  term,  105. 

Injections,  see  Enemata. 

Inorganic  substances ;  elim- 
inated from  body,  229,  230, 
231 ;  in  nerve  tissue,  230. 

Insanity ;  rare  in  family  his- 
tory of  N.,  15 ;  circular, 
108,  109;  delusional,  100 
and  note ;  hypochondriacal, 
123 ;  melancholia,  100  (note), 
108;  moral,  143;  cases 
ascribed  to  mental  stress 

Neurasthenia. 


show  a  neuropathic  hered- 
ity, xviii  (note);— and  N., 
xx,  xxi. 

Insecurity,  state  of  continu- 
ous, in  neurosis  of  anxiety, 
124. 

Insomnia ;  a  fundamental 
symptom,  3, 44  ;  characters 
of,  52,  53,  54  ;  reacts  on  the 
general  condition,  xxv  ; 
may  sometimes  be  due  to 
vaso-motor  disturbances, 
85 ;  in  schoolboys,  22 ;  in 
cerebro- spinal  N.,  93;  part 
cause  of  N.  of  women,  95 ; 
in  traumatic  N.,  103 ;  a 
cause  of  transient  neuras- 
theniform  conditions,  138  ; 
may  be  caused  by  nervous 
fatigue,  155  ; — and  reading 
before  bedtime,  190 ;  "  hyp- 
notic "  treatment  of,  197  ;  a 
contra-indication  to  tea, 
coffee  and  tobacco,  243  ;  as 
a  symptom  of  enteroptosis, 
289;— and  Canard's  belt, 
290 ;  hydrotherapeutic  treat- 
ment of,  319;  effect  of 
different  climates  on,  328, 
329,  333,  334. 

Instincts,  bad,  160  ;  "  formula 
of,"  162;  treatment  of,  164. 

Intellectual  education,  145. 

Intellectual  faculties ;  weak- 
ness of,  42, 72 ;  sluggishness 
of,  in  melancholia,  119 ;  true 
partial  disorder  of,  in  hypo- 
chondriasis  major,  123. 

Intellectual  work  ;  excess  of, 
a  rare  cause  of  N.,  18-24 ; 
affects  circulation  of  en- 
cephalon  much  less  than  do 
emotions,  19,  20  ;  produces 
distressing  impressions  in 
N.,  79;  effect  of,  on  dis- 
tribution of  blood,  in  normal 

25 


386 


INDEX    OF    SUBJECTS. 


subjects  and  neurasthenics, 
133,  134;  how  far  to  be 
permitted  to  neurasthenics, 
189,  190,  191. 

Interpretations,  erroneous, 
137. 

Intestinal  antiseptics,  298, 
299,  300,  302,  303. 

Intestine,  disinfection  of,  298 
-306;  by  antiseptics,  298, 
299;  by  purgatives,  299, 
300 ;  by  washing  out,  300, 
301 ;  by  diet,  302-306. 

Intestine,  large ;  state  of,  in 
spasmodic  constipation, 
266  ;  re-education  of,  270 ; 
irrigation  of,  274,  276,  301; 
state  of,  in  enteroptosis, 
285,  286,  287. 

Intoxications;  causes  of  N., 
xviii,  30,  31,  32;  sometimes 
accompanied  by  neurasthe- 
niform  symptoms,  113 ;  com- 
plicating N.,  186 ;  profes- 
sional, causes  of  hystero-N., 
31,  32. 

Iron ;  amount  eliminated 
daily,  229,  231 ;  proportion 
in  nerve  tissue,  230 ;  in 
Weir  Mitchell's  treatment, 
359. 

Iron-worker,  case  of,  28,  29. 

Irrigation  of  bowel,  274,  301 ; 
increases  spasmodic  con- 
stipation if  too  copious  or 
forcible,  276. 

Irritable  temper;  in  family 
history,  15  ;  in  schoolboys, 
22 ;  in  general  paralysis,  112. 

Irritable  weakness  of  nerve 
elements  ;  N.  denned  as,  2  ; 
characteristic  of  N.,  2,  83, 
308  ;  of  N.  minor,  xvi ;  in 
heart's  action,  83  ;  in  vaso- 
motor  system,  134 ;  in  mind 
and  in  actions,  xvi. 


Irritation,  spinal,  48. 

Isolation,  xxvi,  183-186 ; 
cases  when  not  necessary, 
186 ;  when  absolutely 
necessary,  186 ;  in  Weir 
Mitchell's  treatment,  348- 
352;  duration  of,  352; 
Burkart  and  Leyden's  con- 
tra-indication,  362. 

Italian  lakes,  332. 

JALAP,  279. 

KEFIR,  254,  260,  277,  302, 
305,  306. 

Kidneys ;  disease  of,  some- 
times accompanied  by  neur- 
astheniform  symptoms,  xvii, 
113;  ptosis  of,  287,  288. 

Knee-jerks,  111,  112,  206  and 
note. 

Kola,  235. 

LABOURING  classes,  N. 
in,  11  and  note. 

Lactation,  an  exciting  cause 
of  N.,  35  (note). 

Languor  in  schoolboys,  22. 

Lassitude,  49,  56,  72,  95, 138, 
139,  212  ;  extreme  in  N.  of 
women,  95. 

Late  hours,  27. 

Lateral  sclerosis,  as  an  excit- 
ing cause  of  N.,  34. 

Laugh,  nervous,  in  school- 
boys, 22. 

Lavage  of  stomach,  252,  255. 

Lead  poisoning  ;  a  cause  of 
hystero-neurasthenia,  31, 
32  ;  in  parents,  a  predispos- 
ing cause,  16. 

Leapfrog,  157. 

Learning,  men  of,  N.  in,  11. 

Lecithin,  211,  232. 

Legs  ;  feeling  of  heaviness  in, 
48,  94  ;  rapid  fatigue  of,  51, 


INDEX    OF    SUBJECTS. 


387 


94  ;  localisation  of  amyos- 
thenia  in,  51 ;  paralysis  in, 
77 ;  oedema  in  extremities 
of,  85  ;  pains  in,  94,  99. 

Legumes,  233,  241.  See  also 
under  generic  names. 

Legumin,  220. 

Lentils,  218,  219,  220,  241, 
259,  262,  263,  306;  co- 
efficient of  utilisation  of, 
219,  220. 

Lesions  of  N.,  none  appreci- 
able, 5. 

Lesions  of  nervous  system, 
differential  diagnosis  be- 
tween N.  and,  110-114. 

Lettuce,  241,  262. 

Liberal  professions,  members 
of,  liable  to  N.,  11. 

Life  of  relation,  the,  79  and 
note. 

Lightning  pains ;  shooting 
sensations  in  N.  resembling, 
78 ;  in  general  paralysis,  112. 

Limbs  ;  pains  and  paraesthe- 
sise  in,  48,  78,  79,  94,  99, 
103 ;  amyosthenia  in,  51, 
94 ;  paralysis  of,  77. 

Lime  flowers,  infusion  of,  248, 
263. 

Lips,  trembling  of,  in  general 
paralysis,  112. 

Liqueurs,  243,  253,  260. 

Liquid,  amount  and  kinds  to 
be  drunk,  242,  248,  254, 
259,  260,  263. 

Listlessness,  as  a  cause  of  N., 
11  (note). 

Lithiasis  in  family  history,  13, 
158. 

Lively  neurasthenics,  41. 

Liver,  disease  of;  sometimes 
accompanied  by  neurasthe- 
niform  symptoms,  113  ;  a 
supposed  cause  of  neuroses, 
126. 


Liver,  functional  derangement 
of,  the  supposed  cause  of 
hepatic  N.,  132. 

Liver,  ptosis  of;  sign  of,  287; 
relation  of,  to  N.,  132,  283. 
See  also  Enteroptosis. 

Lobster,  264. 

Locomotor  ataxy  ;  as  an  ex- 
citing cause  of  N.,  34 ;  light- 
ning pains  of,  simulated, 
78  ;  mental  similarities  be- 
tween some  patients  with, 
and  neurasthenics,  52,  180; 
phobia  of,  111,  205,  206; 
differential  diagnosis  be- 
tween N.  and,  111,  206. 

Loins ;  neuralgic  pains  in,  99 ; 
aching  across,  a  sign  of 
enteroptosis,  289  ;  pain  in, 
in  muco-membranous  coli- 
tis, 294. 

Look,  vagueness  of,  in  depres- 
sed neurasthenics,  40. 

Love  troubles,  a  cause  of  N., 
25  ;  the  cause  of  the  neuro- 
sis of  anxiety,  124. 

Lowland  climates,  332,  333. 

Lumbar  puncture,  112. 

Lymphocytosis  of  cerebro- 
spinal  fluid,  absent  in  N., 
present  in  general  paraly- 
sis and  locomotor  ataxy, 
112. 

MACARONI,  261,  263,  303, 

306. 

Mackerel,  217,  264. 
Magnesia,      255 ;      calcined, 

278. 
Maladie  du  doutc,   xxiii,    116, 

117,  118,  121,  122,  179. 
Malaise,  72,   128,    249,    334, 

347;  abdominal,  265. 
Malaria,  as  an  exciting  cause 

of  N.,  32,  33 ;  in  parents,  a 

predisposing     cause,     16 ; 


388 


INDEX    OF    SUBJECTS. 


shivering  stage  of,  simu- 
lated by  general  vascular 
spasm,  84. 

Malformations,  various,  xvii, 
98. 

Malted  starches,  303. 

Malt  extract,  358. 

Manufacturers,  N.  in,  11. 

"  Man  with  slips  of  paper, 
The,"  41,  201. 

Marienbad,  301. 

Maritime  climates,  333,  334, 
335. 

Maritime  resorts,  should  be 
quiet,  335 ;  mountain  cli- 
mates to  be  preferred  to, 
for  most  neurasthenics,  323. 

Massage ;  in  treatment  of 
constipation,  272,  354 ; 
mechanical,  272,  273 ;  phy- 
siological action  of,  341, 
342,  355;  method  of,  353, 
354;  in  Weir  Mitchell's 
treatment,  353-357. 

Masturbation,  25,  97, 132, 169 
364. 

Maternity,  a  cause  of  entero- 
ptosis,  283. 

Meals;  too  copious,  27;  too 
hurried  in  schools,  149; 
hours  and  number  of,  in 
gastro-intestinal  atony,  239, 
245,  246,  247;  not  to  be 
hurried,  247;  hours  and 
number  of,  in  muco-mem- 
branous  colitis,  304,  305, 
306. 

Measles,  106. 

Meat,  212,  219, 227,  232,  244, 
254,  257,  258,  261,  262,  263, 
264,  265,  292,  306;  meat 
diet,  231,  232,  244. 

Medical  men,  N.  in,  11,  170 
(note). 

Meditation,  a  method  of  auto- 
suggestion, 207. 


Mediterranean  coast  of 
France,  333,  338. 

Melancholia  ;  100  (note),  114, 
118,  119,  124,  137,  179; 
intermittent,  108,  119. 

Melancholy,  4,  166,  167,  181, 
due  to  disorder  of  common 
sensation,  80;  a  contra- 
indication to  the  seaside, 
334. 

Melons,  264. 

Membranes,  false,  in  muco- 
membranous  colitis,  293, 
294,  305. 

Memory,  enfeeblement  of,  41, 
70,  71,  72,  103;  accentu- 
ated by  abuse  of  tobacco, 
281 ;  in  general  paralysis, 
112. 

Men,  more  subject  than 
women  to  N.,  10. 

Meniere's  vertigo,  simulation 
of,  76. 

Mental  abnormality  of  genital 
neurasthenics,  98. 

Mental  effort,  incapacity  for, 
22,  72,  93,  104. 

Mental  faculties  all  weakened, 
69,  70,  72. 

Mental  state,  peculiar,  a 
fundamental  symptom,  3, 
44 ;  characters  of,  69-74  ; 
in  N.  of  women,  95;  in 
genital  N.,  100;  in  trau- 
matic N.,  103. 

Merchants,  N.  in,  11. 

Mercury,  poisoning  by,  a 
cause  of  hystero-neurasthe- 
nia,  32. 

Metabolism,  disorders  of,  xvii, 
xviii,  xix,  xx  and  note,  xxi, 
157;  dietetic  treatment  of, 
255,  seqq. 

Metallic  plates  as  a  thera- 
peutic agent,  199. 

Meteorism,  abdominal,  57,58. 


INDEX    OF    SUBJECTS. 


389 


Micturition ;  frequent,  88 ; 
difficult,  88. 

Migraine,  xxi,  xxv,  89  (note) ; 
in  family  history,  15. 

Milk ;  composition  of,  218, 
225;  coefficient  of  utilisation 
of,  220;  lecithin  in,  232; 
antifermenting  action  of, 
302  ;  in  diet,  219,  238,  239, 
240,  241,  254,  258,  260,  261, 

262,  263,  265,  302,  303,  305, 
306,  358,  360,  361,  362. 

Milk  diet,  exclusive,  224,  225, 
226, 228,  231,  244,  245,  257, 
258,  305,  358. 

Milk  puddings,  232  (note), 
262. 

Mineral  substances;  elimin- 
ated from  body,  229,  230, 
231 ;  in  nerve  tissue,  230. 

Mineral  waters;  for  table,  242, 

263,  306;     aperient,    268, 
278,  290,  291,  299. 

Mitchell,  Dr.  Weir,  system  of, 
94, 185,  239,  249,  342,  347- 
360,  362. 

Mobile  heart,  xxii. 

Mobile  kidney,  283;  two 
varieties  of,  287;  the  patho- 
gnomonic  sign  of,  288. 

Mobile  liver,  283,  287. 

Mobile  spleen,  283. 

Monoideism,  passive,  of  chil- 
dren and  hypnotised  sub- 
jects, 160. 

Monosymptomatic  N.,  92. 

Montmirail  water,  268,  299. 

Moral  education,  144,  145, 
159-170. 

Moral  guidance,  xxvii,  200- 
206. 

Moral  hygiene,  xi,  177. 

Moral  ideal  usually  set  before 
children,  159. 

Moral  incompleteness,  117. 

Moral  insanity,  143. 


Moral  overpressure,  25,  26, 
171. 

Moral  prostration,  an  indica- 
tion for  isolation,  186. 

Moral  treatment,  importance 
of,  xxvi,  xxvii,  178, 180, 181, 
200,  348. 

Morality,  experimental,  149. 

Morbid  doubts,  scruples  and 
timidity,  91,  98,  115-118. 

Morphine,  359.  See  also 
Morphinism. 

Morphinism;  a  cause  of  N., 
31 ;  an  indication  for  isola- 
tion, 186. 

Motor  disorders  in  N.,  77,  78. 

Motor  power,  loss  of,  94.  See 
also  Asthenia. 

Motor  functions  of  stomach, 
58,  60,  63,  64,  68,  128,  236, 
237,  240,  245,  246,  252,  254, 
357. 

Mountain  climates,  323-331; 
physiological  effects  of,  324- 
330;  indications  and  contra- 
indications, 326,  327,  329, 
330,  331;  requisites  of 
resorts  in,  327,  331.  See 
also  Altitudes. 

Mourning,  a  cause  of  N.,  26. 

Mouth,drynessof,65;  hygiene 
of,  247. 

Movements;  disordered,  xvii; 
voluntary,  some  neuras- 
thenics exhausted  by  the 
slightest,  95,  340,  341; 
slowness  of,  in  melancholia, 
119  ;  passive,  341, 342,  355. 

Muco-membranous  colitis,  see 
Colitis. 

Mucus  in  stools,  292,  293,  294, 
298,  301. 

Multiple  personality,  xxiv. 

Muscles ;  lack  of  tone  in,  xxii; 
cramps,  fibrillar  contrac- 
tions, and  contractures  of, 


390 


INDEX     OF     SUBJECTS. 


77 ;  action  on,  of  massage, 
353. 

Muscular  asthenia,  see  Asthe- 
nia. 

Muscular  atrophy,  49,  50 ; 
Progressive,  77. 

Muscular  exercise;  kind  re- 
quired for  children  with 
neuropathic  heredity,  152- 
158 ;  for  neurasthenics,  340 
-345;  need  of  regulating, 
340,  345 ;  physiological 
effects  of,  339. 

Muscular  immobility,  bad 
effects  of,  340,  342,  353. 

Muscular  overpressure,  a  sup- 
posed cause  of  N.,  28,  29, 
30  ;  may  aggravate  N.,  345; 
seaside  good  for,  334. 

Mushrooms,  241. 

Music,  191. 

Mustard,  242,  248,  263. 

Mutton,  217,  241,  248,  261, 
306. 

Myelasthenia,  93,  94. 

Myelitis,  49. 

Myocardium,  eufeeblement  of, 
82. 

Myopathy,  49. 

NAPHTHOL,  298,  299. 

Narrowing  of  field  of  vision, 
86. 

Nausea ;  in  Reichmann's  dis- 
ease, 66;  in  neurasthenic 
vertigo,  76  ;  in  muco-mem- 
branous  colitis,  297. 

Neck,  crackings  at  back  of, 
46. 

Nephroptosis,  see  Floating 
kidney. 

Nerve  elements ;  N.  due  to 
modification  of,  1,  5,  135 ; 
Erb's,  Beard's  and  Fere's 
theories  as  to  the  nature  of 
this  change,  135,  136. 


Nervo-motor  dyspepsia,  55. 
See  also  Atony,  gastro-in- 
testinal. 

Nervosisme  aigu,  91. 

Nervosity,  vii. 

Nervous  debility,  congenital, 
xvi,  98. 

Nervous  energy;  N.  a  chronic 
enfeeblement  of,  2,  136 ; 
neither  regularly  distribu- 
ted nor  uniformly  sustained 
in  N.,  136.  See  also  Asthe- 
nia. 

Nervous  exhaustion,  a  syno- 
nym for  N.,  vii,  2. 

Nervous  fatigue,  caused  by 
certain  exercises,  154, 155. 

Nervous  heredity.  See  Here- 
dity. 

Nervous  system,  organic  dis- 
eases of;  how  they  may 
cause  N.,  33,  34  ;  diagnosis 
of,  from  N.,  110-113,  206 
and  note  ;  resemblances  in 
mental  state  of  patients 
with,  and  neurasthenics,  52, 
180,  181  ;  symptoms  of, 
simulated,  77,  78,  92. 

Nervous  system,  instinctive 
need  to  stimulate,  235,  242, 
243. 

Nervous  weakness,  a  synonym 
for  N.,  2. 

Neuralgia;  in  schoolboys, 22 ; 
"general,"  78  ;  in  neuralgic 
N.,  92;  in  cerebro-spinal 
N.,  93 ;  in  genital  N.,  99 ; 
in  limbs,  an  alleged  contra- 
indication to  Weir  Mit- 
chell's treatment,  362. 

Neuralgic  N.,  92. 

Neurasthenia;  causation, xviii 
-xx,  4,  5,  6-37,  126-140, 
180,  181,  256;  definition, 
xviii,  1,  2;  differential  diag- 
nosis from  cerebral  tumour, 


INDEX    OF    SUBJECTS. 


391 


113 ;  from  general  paralysis, 
111,  112 ;  from  false  pre- 
paralytic  N.,  112 ;  from 
hypochondriasis,  115,  119- 
123  ;  from  locomotor  ataxy, 
111,  206;  from  the  maladie 
du  doute,  115-118;  from 
melancholia,  115,  118,  119 ; 
from  the  neurosis  of  anxiety, 
123,  124 ;  from  various  or- 
ganic diseases,  113 ;  distri- 
bution, ethnographic,  7,  8 ; 
according  to  age,  sex,  and 
profession,  9,  10,  11 ;  in 
town  and  country,  9,  11 
(note) ;  forms  of,  90-104  ; 
pathogeny,  xv-xx,  5,  126- 
140  ;  prophylaxis,  in  chil- 
dren, 141-170;  in  adults, 
171-174 ;  stigmata  (leading 
symptoms),  3,  44-74;  sec- 
ondary symptoms,  75-89 ; 
treatment  of  N.  generally, 
xxv,  xxvi,  xxvii,  175-345 ; 
of  N.  of  women,  346-362  ; 
of  genital  N.,  363-368. 
Misuse  of  the  word  Neuras- 
thenia, v,  105  ;  N.  shows 
itself  by  a  diminution  of 
nervous  energy,  2, 136, 138; 
systems  chiefly  affected  by, 
2  ;  fixity  of  leading  symp- 
toms, 3 ;  a  somatic  disease, 
3,  137 ;  relation  between 
psychical  processes  and  N., 
3,  4, 138, 139, 140, 180, 181 ; 
an  exhaustion  disease,  3,  4, 
120,  180  ;  a  disorder  of  the 
energy,  140  ;  not  a  modern 
disease,  6 ;  very  common 
and  growing  more  frequent, 
6 ;  "  the  disease  of  the 
century,"  7  ;  causes  of  re- 
cent increase,  8,  9 ;  often 
the  penalty  of  uselessness, 
idleness  and  vanity,  28 ; 


may  come  on  suddenly,  34: 
may  occur  in  a  family  not 
neuropathic  hitherto,  36 ; 
causes  almost  always  mul- 
tiple, 37;  treatment  depends 
on  appreciation  of  part 
played  in  causation  by 
principal  and  accessory 
factors  respectively,  37 ; 
affects  both  somatic  and 
psychical  functions  of  ner- 
vous system,  69, 180;  some- 
times accompanied  by  a 
slight  degree  of  scruples, 
doubts,  phobias,  melan- 
cholic depression,  or  hypo- 
chondriacal  obsessions,  115, 
116, 118;  wrongly  supposed 
to  be  a  disease  of  the 
imagination,  120,  138,  139, 
140;  but  symptoms  arising 
from  fear  or  auto-suggestion 
are  often  added  to  those  due 
to  nervous  exhaustion,  139, 
140,  180,  181;  vaso-motor 
system  in,  133, 134;  defined 
by  Anjel  as  a  vaso-motor 
neurosis,  135 ;  vaso-motor 
origin  of  certain  symptoms, 
80,  85;  due  to  a  modifica- 
tion of  all  the  nerve  centres, 
135 ;  treatment  differs  from 
that  of  hysteria,  179;  next 
to  hysteria,  the  nervous 
affection  in  which  psychical 
treatment  is  most  useful, 
179,  180;  personality  not 
so  profoundly  altered  as  in 
hysteria,  198.  Heredity 
and  N.,  xix,  12-16,  17,  36, 
91,  141;  N.  and  arthritic 
diathesis,  xx,  13,  158,  256 ; 
N.  and  gout,  13,  256;  N. 
and  obesity,  256,  260;  N. 
and  visceral  ptosis,  xxii, 
282-291  ;  N.  and  muco- 


392 


INDEX    OF    SUBJECTS. 


membranous  colitis,  291, 
297  ;  N.  and  insanity,  xx, 
xxi ;  N.  and  chilblains, 
"dead"  fingers,  arterio- 
sclerosis, Bright's  disease, 
tuberculosis,  and  heart 
disease,  xx  and  note ;  N. 
and  various  defects,  xxii ; 
N.  and  disintegration  of  the 
personality,  xxiv,  xxv ;  N. 
and  degeneracy,  xviii-xxii, 
91,98.  Acute  N.,  91,  108; 
cardiac,  80,  92 ;  cerebral, 
xxvi,  93,  130, 189,  330,  336, 
337,  338,  342,  362  ;  cerebro- 
spinal,  93,  330,  342  ;  false 
preparalytic,  112  ;  gastric, 
92;  genital,  87,  93,  97-100, 
363-368;  hemi-,  92;  hepa- 
tic, 132, 213 ;  hereditary,  14, 
66,  91,  130;  hystero-,  32, 
53,  78,  100,  115,  198; 
monosymptomatic,  92 ; 
neuralgic,  92;  of  women, 
51,  73,  93,  94-97,  249,  342, 
346-362 ;  precocious,  10, 14, 
91;  secondary,  212,  213; 
spinal,  93,  94;  traumatic, 
34,  35,  53,  93, 100-104, 115, 
139,368;  N. minor,  xvi,seqg. 

Neurasthenic  asthenopia,  86, 
93, 103. 

Neurasthenics ;  examination 
of,38,39,42,43,204;  varieties 
of,  39-42;  give  an  inco- 
herent and  diffuse  account 
of  their  symptoms,  42  ; 
unconsciously  magnify  their 
symptoms,  52;  emotional, 
71;  impressionable,  71, 182; 
suggestible,  72,  74,  182; 
greatly  affected  by  their 
environment,  74 ;  not  al- 
ways hypnotisable,  74, 197 ;  j 
fully  half  those  called 
neurasthenics  are  not  really 


so,  110;  must  be  forbidden 
the  society  of  those  like 
them,  192  ;  more  good  done 
as  a  rule  by  an  appeal  to 
their  intelligence  than  by 
an  appeal  to  their  feelings, 
196  ;  bear  changes  of  regi- 
men badly,  236 ;  very 
sensitive  to  climatic  in- 
fluences, 78, 322  ;  not  always 
selfish  and  self-centred, 
xxvii. 

Neurasthenic  dimidiee,  92. 

Neurastheniform  symptoms, 
xvii,  xix,  xxii,  112,  113, 
212,  213. 

Neuritis,  49. 

Neuro-arthritic  diathesis,  256, 
292. 

Neuro-arthritic  heredity,  a 
cause  of  N.,  13,  14,  15,  17, 
36,  141,  142,  158. 

Neuropaths,  symptomatic 
classification  of,  114. 

Neuroses,  connection  of  N. 
with  other,  xx,  xxiii. 

Neurosis  of  Anxiety,  the, 
xxii,  123,  124. 

Neurosis  from  Exhaustion, 
the,  vii. 

Neurosis,  the  traumatic,  101. 

"  Neurotic ;"  all  patients  with 
nervous  diseases  formerly 
described  as,  110 ;  meaning 
of  word,  xix. 

Nice,  333. 

Nightmares,  53,  103. 

Night  terrors  in  children, 
often  caused  by  terrifying 
stories,  168. 

Nitrogenous  coefficient,  the, 
222,  223. 

Nitrogenous  food,  see  Proteid 
food. 

Nocturnal  emissions,  88,  99, 
366. 


INDEX    OF    SUBJECTS. 


393 


Nomenclature  of  diseases, 
value  of,  107. 

Nose,  feeling  of  pressure  and 
tightness  at  root  of,  46. 

Numbness  in  limbs,  feeling 
of,  78,  79,  103. 

Nurse,  a  well  trained,  neces- 
sary in  N.  of  women,  97, 350. 

Nursing  sick  relatives,  a 
cause  of  N.  of  women,  95. 

Nutrition,  general,  xx  (note), 
56,  59,  60,  64,  96,  211,  237, 
238,  244, 255,  347;  derange- 
ment of  by  toxic  substances, 
a  cause  of  N.,  31;  vitiation 
of,  by  dyspeptic  states,  as  a 
cause  of  N.,  4,  129-132; 
association  of  N.  with 
disorders  of,  xx  and  note; 
effects  on,  of  mountain 
climates,  326,  328,  331 ;  of 
active  exercise,  339 ;  of 
massage  and  faradisation, 
355. 

Nutrition  of  nerve  elements, 
N.  thought  to  be  a  derange- 
ment of,  1,  135. 

Oatmeal,  218,  260,  263. 

Obesity;  tendency  to,  158; 
association  of,  with  N.,  256, 
260 ;  Oertel's  treatment  of, 
345. 

Obsessions,  70, 72, 91,  92, 124 ; 
hypochondriacal,  73,  98, 
115,  122;  treatment,  182, 
197,  200,  204,  205 ;  anxious 
obsessions  a  contra-indica- 
tion  to  high  altitudes,  331. 

Obstinacy,  160. 

Occipital  headache,  45. 

Occupation,  distribution  of  N. 
according  to,  10,  11  and 
note. 

Oedema,  transient,  85,  86. 

Oertel's  treatment  of  obesity, 
345. 


Officers,  N.  in,  11. 

Oil  enemata,  274,  276. 

Oligocythaemia,  relative,  326. 

Old  age,  N.  very  rare  in,  9. 

Omelettes,  261. 

Onions,  262,  264. 

Open  air  treatment,  xxvi. 

Orange  flowers,  infusion  of, 
263. 

Oranges,  262,  264,  271,  301. 

Organic  acids  of  fermentation, 
61,  62,  295. 

Organic  diseases  of  nervous 
system,  see  Nervous  system, 
organic  diseases  of. 

Organic  life;  nerves  of, 
affected  in  N.,  2 ;  functions 
of,  produce  distressing  im- 
pressions in  N.,  79. 

Organic  sensations ;  vividly 
perceived,  71 ;  disorders  of, 
72,  79,  80. 

Ovarian  diseases,  as  a  cause 
of  N.,  35,  36,  94,  132. 

Overfeeding;  Weir  Mitchell's 
method,  357,  358;  Ley- 
den's,  360;  Binswanger's, 
360,  361,  362. 

Overpressure ;  ,a  leading  cause 
of  N.,  1,9,  17-30,  36,  94; 
intellectual,  18-25,  94,  155, 
186,  189,  330,  334;  in 
schools,  21-25;  symptoms 
of,  in  schoolboys,  22 ;  chil- 
dren incapable  of,  24; 
Spencer  on  evil  effects  of, 
172 ;  moral,  25,  26,  28,  33, 
34,  36,  131,  133,  189,  330; 
caused  by  certain  physical 
exercises,  155;  muscular, 
27,  28,  29,  30,  94,  186,  334, 
345;  of  whole  being,  95; 
healthy  nervous  systems, 
not  readily  upset  by,  xviii 
(note). 

Oxalic  acid,  certain  vegetables 


394 


INDEX    OF    SUBJECTS. 


too  rich  in,  for  the  gouty, 

259 

Oxaluria,  88,  89  (note). 
Oxybutyric  acid,  xix. 
Oysters,  261. 

PACK,  wet,  309,  312;  with 
friction,  309,  310,  314; 
dripping,  without  friction, 
310,314;  epigastric,  320,321. 

Pack,  damp,  319,  320. 

Pain ;  various  forms  of,  in  N., 
78  ;  on  pressing  spinous 
processes,  48 ;  in  simple 
hyperchlorhydria,  65;  how 
relieved,  65 ;  in  Reichmann's 
disease,  67 ;  fixed  and  local- 
ised, in  monosymptomatic 
N.,  92  ;  various  in  cerebro- 
spinal,  N.,  93 ;  in  back  and 
Hmbsin spinal  N.,  94 ;  vague, 
diffuse,  in  N.  of  women, 
96;  in  thighs  and  loins,  in 
genital  N.,  99;  in  genital 
organs  in  genital  N.,  367 ; 
localised,  in  traumatic  N., 
103;  in  muco-membranous 
colitis,  294,  302,  305; 
precordial,  hydrotherapeu- 
tic  treatment  of,  321 ;  in 
viscera  and  limbs,  held  by 
Burkart  and  Leyden  to  be 
a  centra-indication  to  Weir 
.Mitchell's  treatment,  362. 
See  also  Headache,  Neural- 
gia, and  Rachialgia. 

Pallor,  84. 

Palpitation  of  heart ;  in 
schoolboys,  22 ;  in  atonic 
dyspepsia,  57  ;  characters 
of,  in  N.,  81 ;  in  cardiac 
N.,  92;  in  genital  N.,  99; 
a  contra-indication  to  tea, 
coffee,  and  tobacco,  243 ; 
in  mountain  climates,  328, 
331 ;  at  seaside,  334. 


Pancreatine,  250. 

Paraesthesiae,  various,  45,  46, 
47,  48,  78,  79,  80  (note) ; 
vaso-motor  origin  of,  134. 

Paralysis,  General,  see  Gen- 
eral paralysis. 

Paralysis  true,  does  it  occur  in 
N.?  51,  77,  78. 

Paraphasia,  89  (note). 

Parents;  diseases  of,  a  pre- 
disposing cause  of  N.,  15, 
16 ;  carelessness  of,  16 ; 
faults  of,  contagious,  160; 
emotions  of,  contagious, 
168. 

Pareses,  motor,  of  eyes,  112. 

Partridge,  217,  262. 

Passions,  a  cause  of  N.  175. 

Passive  movements,  341, 
342,  355. 

Pastry,  264,  360. 

Pathogeny  of  N.,  xv-xx,  5, 
126-140. 

Pathological  chemistry  of 
stomach,  60-68,  129. 

Pathological  physiology  of  N.f 
obscure,  5. 

Patience,  required  in  exam- 
ining neurasthenics,  39,  42. 

Peaches,  218.  259,  262,  264. 

Pears,  218,  242,  259. 

Peas,  218,  219,  220,  241  and 
note,  259,  262,  263,  306. 

Peasants,  N.  in,  11  (note). 

Penis,  malformations  of,  98. 

Pepper,  242,  248,  263. 

Pepsine,  gastric  secretion  of; 
in  gastro-intestinal  atony, 
61,  62 ;  in  Reichmann's 
disease,  66,  68. 

Pepsines,  commercial,  250. 

Perch,  261. 

"  Periodic  depression,"  108, 
109. 

Persecutes  auto-accusateurs,  100 
and  note. 


INDEX     OF     SUBJECTS. 


395 


Personality,  weakening  of, 
69,  72,  182  ;  substitution  of 
new  for  old,  185 ;  not  so 
profoundly  altered  in  N.  as 
in  hysteria,  198;  disintegra- 
tion of,  and  N.,  xxiv,  xxv. 

Persuasion,  psychotherapy 
by,  xxvi,  xxvii,  193-196. 

Pessimism ;  common  in  neuro- 
paths, 166 ;  incessant 
thwarting  a  cause  of,  167. 

Pheasant,  262. 

Phenol,  a  product  of  proteid 
fermentation,  295. 

Phobias,  4,  73,  74,  111,  115- 
118, 121, 122  ;  treatment  of, 
186, 197,  206 ;  high  altitudes 
contra-indicated,  331. 

Phosphatine,  263. 

Phosphaturia,  88,  89  (note), 
231. 

Phosphoruria,  89,  231. 

Phosphorus,  phosphoric  acid, 
and  phosphates  ;  88,  89  and 
note,  211,  229-234 ;  amount 
of,  in  nervous  system, 
230 ;  amount  eliminated 
daily,  231 ;  amount  in  milk, 
eggs,  meat,  232 ;  in  vege- 
tables, 232,  233;  assimila- 
tion of,  232,  233 ;  adminis- 
tration of,  233,  234. 

Photography,  191. 

Physical  agents,  superior  to 
drugs  in  the  treatment  of 
N.,  xxvi,  348. 

Physical  conditions,  defective, 
a  cause  of  N.,  20. 

Physical  education,  144,  145, 
146-158 ;  insufficient,  a 
predisposing  cause  of  N., 
16. 

Physical  exercises;  for  chil- 
dren, 152-158 ;  for  neuras- 
thenics, 189,  339-345 ; 
need  of  regulating,  340, 345 ; 


physiological  effects  of, 
339. 

"  Physical  morality,"  147. 

Physical  overpressure,  see 
Overpressure,  muscular. 

Physician ;  moral  influence 
of,  xxvi,  178,  182,  183,  192, 
193,  199,  200-206;  neces- 
sary qualities  and  attitude 
of,  39,  42,  74,  200,  201,  202, 
203,  206,  302,  307,  351; 
should  not  see  patients  too 
often,  202. 

Physiognomy,  see  Facies. 

Physiological  misery,  143. 

Phytin,  233. 

Pianist,  case  of  a,  50,  51. 

Pickles,  259. 

Pike,  261. 

Plains,  climate  of,  332,  333. 

Plaque  occipitale,  45. 

Plaque  sacree,  47. 

Pleasure,  pursuit  of,  apt  to 
unbalance  nervous  system, 
28. 

Plethysmograph,  133. 

Plombieres,  301. 

Plums,  259,  262,  264. 

Plunge  baths,  158. 

Podophyllin,  278,  280,  281. 

Political  and  economical 
conditions,  abrupt  change 
in,  the  cause  of  the  recent 
increase  in  N.,  8,  9. 

Pollutions,  nocturnal,  88,  99, 
366. 

Polyuria,  88,  89  (note),  104. 

Poor,  N.  in  the,  26. 

Pork  butcher's  meat,  264. 

Posture,  exaggerated  effect 
of,  on  pulse  rate,  85  (note). 

Potatoes,  218,  219,  220,  241, 
259, 262,  264,  303,  306, 360, 
361. 

Potted  foods,  264. 

Poultry,  217,  241. 


396 


INDEX    OF    SUBJECTS. 


Precocious  N.,  10,  14.  See 
also  Hereditary  N. 

Precordial  anxiety,  92,  93, 
99,  116  (note). 

Precordial  pains,  hydrothera- 
peutic  treatment  of,  321. 

Pregnancies,a  cause  of  entero- 
ptosis,  285. 

Pressure,  sensations  of,  46, 
47. 

Priapism,  in  genital  N.,  99. 

Pricking  sensations,  78. 

Prisoner's  base,  157. 

Profession ;  distribution  of 
N.  according  to,  10,  11  and 
note,  170  (note);  value  of 
a,  169,  170. 

Professional  intoxications, 
causes  of  hystero-  N.,  31, 
32. 

Progressive  muscular  atro- 
phy, 77. 

Prophylaxis ;  double  aim  of, 
141;  in  children,  141-170; 
in  adults,  171-174. 

Prostatorrhcea,  99,  363,  364. 

Prostration,  moral,  186. 

Proteid  food;  212,  214-222, 
225-229,  241,  253,  254, 
258,  304  ;  digestion  of,  220, 
221 ;  products  of  fermenta- 
tion of,  295. 

Proteiform  Neuralgia,  vii. 

Pseudo- anaemia,  80  (note). 

Pseudo-membranous  entero- 
colitis,  see  Colitis,  muco- 
membranous. 

Psychasthenia,  117. 

Psychical  action  of  various 
hygienic  measures,  182, 183, 
184,187,188,189. 

Psychical  state  in  genital  N., 
100. 

Psychical  disorders  of  N., 
69-74,  115,  118,  121;  in 
hereditary  N.,  91 ;  in  N.  of 


women,  95,  96,  346;  in 
genital  N.,  100,  364,  366; 
in  traumatic  N.,  103,  104. 

Psychology,  106. 

Psychoses ;  need  of  exact 
diagnosis  in,  106,  109 ; 
periodical,  108  ;  connection 
of  N.  with,  xx,  xxi,  xxii. 

Psychotherapeutics,  xxvi, 
xxvii,  178-208 ;  indirect, 
183-192  ;  direct,  192-208  ; 
three  kinds  of  direct,  193  ; 
by  persuasion  or  reasoning, 
xxvi,  xxvii,  118,  193-196, 
200-206  ;  by  hypnotic  sug- 
gestion, 196-200. 

Psycrofore,  Winternitz',  367. 

Ptomaines,  295. 

Ptosis,  visceral ;  its  relations 
to  N.,  xxii,  132,  283,  284; 
description  of,  285-288 ; 
symptoms  due  to,  shown 
by  neurasthenics,  288,  289 ; 
treatment,  289,  290,  291. 
See  also  under  names  of 
various  organs. 

Puberty  ;  N.  occurring  at,  10, 
14,  91 ;  a  cause  of  N.,  36  ; 
need  of  supervision  at,  169. 

Public  catastrophes,  the  com- 
monest cause  of  traumatic 
N.,  102. 

Pulsations,  audible,  87. 

Pulsations,  visible  ;  of  caro- 
tids, 81;  of  superficial  ar- 
teries, 81  (note) ;  epigastric, 
81  (note). 

Pulse  ;  quickened,  81, 82, 104, 
331 ;  slowed,  82,  83 ;  irregu- 
lar, 82  ;  intermittent,  104  ; 
small,  83,  84,  104;  com- 
pressible, 83 ;  in  neurasthe- 
nic angina,  83,  84;  in 
traumatic  N.,  104 ;  effect 
of  immobility  on,  342,  353  ; 
of  exercise,  339 ;  of  massage, 


INDEX    OF    SUBJECTS. 


397 


353  ;  of  faradisation,  355  ; 
of  mountain  climates,  324, 
325,  326,  328,  330,  331 ;  of 
maritime  climates,  334. 

Pupils  ;  inequality  of,  in  gen- 
eral paralysis,  112  ;  in  loco- 
motor  ataxy,  206 ;  reaction 
of,  in  locomotor  ataxy,  111, 
206  ;  in  N.,  206  and  note. 

Purgatives ;  see  Aperients. 

Purin  bases,  223  (note),  262 
(note). 

Putrefaction,  intestinal,  295, 
305. 

Pylorus,  stenosis  of,  128. 

Pyrosis,  in  simple  hyperchlor- 
hydria,  65. 

RACHIALGIA;  a  leading 
symptom,  3,  44,  115,  117, 
212  ;  characters  of,  47,  48  ; 
in  cerebro-spinal  N.,  93 ;  in 
spinal  N.,  94 ;  in  N.  of 
women,  96  ;  in  genital  N., 
99  ;  may  give  rise  to  hy- 
pochondriacal  ideas,  73 ; 
hydrotherapeutic  treatment 
of,  321;  diminishes  in  moun- 
tain climates,  329. 

Radishes,  241,  264. 

Railway  accidents,  a  cause  of 
traumatic  N.,  35,  101,  102. 

Railway  spine,  101. 

Raspberries,  259. 

Reading,  under  what  condi- 
tions permissible,  190. 

Reality,  loss  of  sense  of,  117. 

Reasoning,  psychotherapy 
by ;  xxvi,  xxvii,  121,  122, 
193-196,  200-206  ;  may 
strengthen  energy  and 
personality,  195  ;  com- 
pared with  suggestion,  194, 
195,  196. 

Recreations,  value  of,  344. 

Redness, blushes  of,on  skin,85. 


Reflex  action  from  unhealthy 
organs,  as  a  cause  of  N., 
126. 

Reflexes,  xxi,  89  (note),  111, 
112,  206. 

Regressive  evolution  of  civil- 
ised nations,  not  the  cause 
of  the  increase  in  N.,  7,  8. 

Regularity  of  hours ;  of  meals 
and  sleep,  188 ;  of  going  to 
stool,  267,  269,  270. 

Regurgitations,  acid,  57,  65, 
67,  68. 

Reichmann's  disease,  64,  66, 
67,  68,  255. 

Relation,  life  of,  functions 
produce  distressing  impres- 
sions in  N.,  79. 

Relaxing  climates,  an  exciting 
cause  of  N.,  35  (note). 

Remorse,  a  cause  of  N.,  25. 

Resonance,  gastric,  57. 

Respiration  ;  shallow,  xxi,  89 
(note) ;  embarrassed,  265  ; 
effect  of  mountain  climates 
on,  324,  325,  326,  328,  330; 
of  exercise  on,  339,  344. 

Rest,  179,  190,  191,  237,  247, 
265,  332 ;  after  meals,  282  ; 
in  Weir  Mitchell's  treat- 
ment, 348,  352,  353. 

Retention  of  urine  in  loco- 
motor  ataxy,  111. 

Retort,  the  body  not  a,  306. 

Reverses  of  fortune,  a  cause 
ofN.,  9,26,  175. 

Rhamnus  Frangula,  decoction 
of  bark  of,  280. 

Rheumatism ;  and  hydrother- 
apy,  315,  316,  317;  high 
altitudes  unfavourable  to, 
331. 

Rheumatoid  pains ;  some- 
times produced  by  cool 
shower-baths,  313;  often 
aggravated  at  seaside,  334. 


398 


INDEX    OF    SUBJECTS. 


Rhubarb  ;  (food)  259  ;  (drug) 

280,  281. 
Rice,  218,  220,  241,  260,  263, 

303,  306. 
Riding,  344,  366. 
Riviera  di  Ponente,  333. 
Romberg's  sign,  111,  206. 
Rotatory  vertigo,  76. 
Rowing,  157,  344. 
Rubinat  water,  291,  299. 
Ruin,     false     ideas     of,     in 

melancholia,  119. 
Running,  152,  157. 
Rusks,  305,  306,  360. 
Russia;  N.  in,  7;  social  life 

in,  27. 

SADNESS,  look  of,  in  school- 
boys, 22. 

Sago,  241,  303. 

Salacetol,  299. 

Salad,  264. 

Salicylic  acid,  299. 

Saline  aperients ;  taken  by 
neurasthenics,  268 ;  keep 
up  constipation,  278 ;  in 
constipation  of  enteroptosis, 
290,  291 ;  in  muco-mem- 
branous  colitis,  299.  See 
also  Seidlitz  powder ;  Mag- 
nesia, sulphate  of;  Soda, 
sulphate  of;  and  Mineral 
waters  (aperient). 

Salmon,  217,  264. 

Salol,  298. 

Salt  (condim  ent) ,  242, 248, 253. 

Salts  in  food,  225,  229-233. 

Sauces,  253,  264. 

Savoy,  subalpine  health  re- 
sorts in,  331. 

Scalp,  hyperaesthesia  of,  47. 

Scammony,  279. 

Scarlatina,  106. 

Schoolboys ;  N.  in,  11,  21-25 ; 
symptoms  of  over  brain - 
pressure  in,  22. 


Schools ;  over-pressure  in, 
21-25,  148;  defective  hy- 
gienic conditions  in  board- 
ing-, 24,  25,  148,  149,  150. 

Scientists,  N.  in,  11. 

Sclerosis,  Disseminated  ;  as  a 
cause  of  N.,  34;  also  52, 
180. 

Scotch  douche,  313,  316,  317, 
319,  321. 

Scruples,  morbid,  91,  98,  114, 
115-118,  121,  123. 

Sea  bathing,  158,  333. 

Seaside;  climate  of,  333,  334; 
resorts,  should  be  quiet, 
335 ;  inferior  to  mountain 
climates  in  most  cases  of 
N.,  323. 

Secretions,  action  of  massage 
on,  353. 

Secretions,  internal,  defects 
of,  xvii,  xx  (note). 

Sedentary  life,  ill  effects  of, 
25,  147,  148. 

Seidlitz  powder,  268,  280, 
281. 

Self-accusing  patients  with 
delusions  of  perse<  ution, 
100  and  note. 

Self-confidence;  loss  or,  71, 
164 ;  need  of  encouraging, 
162;  treatment  to  ^ive, 
162,  163,  189,  191.  344. 

Self-esteem;  vexaiio.is  of, 
28. 

Self-involvement,  xx\ii 

Selfishness;  freque  ;  in 
neuropaths,  160,  166 ;  but 
by  no  means  inva^  n>le, 
xx  vi. 

Semolina,  263,  303. 

Sensations,  organic  ;  dly 

perceived,  71,  7J  ;  10- 
foundly  disorder  u  80; 
disorders  of,  72.  J,  80; 
in  traumatic  N..  103 


INDEX    OF    SUBJECTS. 


399 


Senses,  special,  disorders  of, 

85,  86,  87. 
Sensitiveness  to   cold,    heat, 

and  atmospheric  influences, 

40,  78,  322. 
Sex,      distribution      of      N. 

according  to,  10. 
Sexual    appetite,    diminution 

in,  88,  111. 
Sexual   excitement    &c.,    see 

Genital. 

Shame,  in  genital  N.,  100. 
Shell-fish,  264. 
Shivering,  84. 
Shock  ;  a  cause  of  N.,  34,  35, 

36,  91,  102 ;  moral,  a  much 

more    important    cause   of 

traumatic  N.  than  physical, 

35,  102. 

Shooting  pains,  78. 
Shower-baths  ;  not  a  panacea, 

179.     See  also  Douches. 
Shrimps,  264. 
Sight,  disorders  of,  86,  93. 
"Sigmoidal  cord,"  266,  285, 

287. 

Similar  heredity,  12. 
Simulation   of   symptoms    of 

organic  or  infective  diseases 

by  N.,  59,  67,  76,  77,  78, 

81,  84,  92. 
Singlesticks,  155. 
Skate,  217,  261. 
Skatol,  295. 
Skin ;  in  severe  gastro-intesti- 

nal  atony,  59  ;  hygiene  of, 

158 ;  action  of  massage  on, 

353. 

Skipping,  157. 
Sleep ;     insufficiency    of,     in 

schools,  xxvii,  25,  149 ;  in 

society,  27  ;  frequent  desire 

for,     in     schoolboys,     22 ; 

disorders    of,     from     toxic 

substances,  a  cause  of  N., 

31. 


Sleeplessness,  see  Insomnia. 

Slips  of  paper,  The  man  with, 
41,  201. 

Sloth ;  in  schoolboys,  22 ; 
in  neurasthenics,  191. 

Smell,  disorders  of,  87. 

Smith,  case  of  a,  28,  29. 

Smoking,  excessive,  a  cause 
of  N.,  30,  36;  contra-indi- 
cations  to,  243. 

Social  conditions,  abrupt 
change  of,  the  cause  of  the 
increase  in  N.,  8,  9. 

Social  duties,  neglect  of,  71, 
72. 

Society  life,  a  cause  of  N., 
26,  27,  28 ;  in  Russia,  27. 

Society,  what  suitable  and 
what  unsuitable  to  neuras- 
thenics, 191,  192. 

Sodium  bicarbonate,  242,  250, 
254  ;  action  of,  254,  255. 

Solar  radiation,  action  of,  328. 

Sole,  217,  261. 

Solitude;  sought  out  by 
neurasthenics,  72,  191 ; 
injurious,  191. 

Somnolence ;  in  schoolboys, 
22 ;  in  gastro-intestinal 
atony,  236. 

Sorrel,  259,  264. 

Sorrow,  a  cause  of  N.,  25, 
181,  189. 

Soup,  238,  257,  262,  263,  303, 
360,  361,  362. 

Spasm,  intestinal,  266,  272, 
273,  288,  295. 

Spasmodic  constipation,  266, 
272,  273. 

Spastic  paralysis,  as  an 
exciting  cause  of  N.,  34. 

Speech ;  of  depressed  neuras- 
thenic, 40 ;  of  lively  neuras- 
thenic, 41 ;  in  genital  N., 
100 ;  in  traumatic  N.,  103  ; 
in  general  paralysis,  112. 


400 


INDEX    OF     SUBJECTS. 


Spermatorrhoea,  99  ;    prosta-  I 
torrhoea  often  mistaken  for, 
99 ;  treatment  of,  366,  367, 
368. 

Spices,  253,  263,  264,  292. 

Spinach,  218,  243,  and  note, 
259,  262. 

Spinal  cord,  organic  diseases 
of;  as  an  exciting  cause  of 
N.,  33,  34 ;  some  patients 
with,  unconsciously  magnify 
their  symptoms,  52. 

Spinal  cord,  supposed  lesions 
of,  in  traumatic  N.,  101. 

Spinal  curvature,  xxii. 

Spinal  irritation,  48,  94. 

Spinal  N.,  48,  93,  94. 

Spine ;  pains  and  paraesthesiae 
in,  3,  44,  47  and  note,  48, 
94;  apparent  stiffness  in, 
103  ;  ice-bags  to,  367. 

Spine,  Railway,  101. 

Spinous  processes,  pain  on 
pressing,  48. 

Splashing  sound  produced  by 
gastric  succussion,  57,  58. 

Spleen ;  disease  of,  a  supposed 
cause  of  neuroses,  126 ; 
ptosis  of,  283. 

Splenoptosis,  283. 

Sponging,  309,  310,  314. 

Standing,  very  tiring  in  N.  of 
women,  95. 

Starch  and  starchy  foods ; 
214, 248,  254,  265,  302,  305, 
306 ;  diminish  intestinal  pu- 
trefaction and  promote  di- 
gestion of  proteids,  303 ; 
malted,  303.  See  also 
Carbohydrates. 

Starvation  diets,  257. 

Stasis,  gastric,  60,  64,  68, 128, 
236,  237,  240,  246,  252, 
254,  357. 

Stasophobia,  74. 

Stiffness ;     sensation     of,    in 


spine,  47 ;  apparent,  in 
spine  and  limbs  in  traumatic 
N.,  103. 

Stigmata  of  N.,  44. 

Stigmata  of  degeneracy,  xxi. 

Stimulants,  134,  235, 242,  243. 
See  also  Alcohol. 

Stimulation,  instinctive  need 
of,  235,  242,  243. 

Stockbrokers,  N.  in,  170 
(note). 

Stomach ;  catarrh  of,  357 ; 
disorders  of,  as  a  cause  of 
N.,  35, 126-132  ;  distension 
and  dilatation  of,  57,  58, 
60,  64,  68,  128,  129,  236, 
237,  245,  246,  251,  284,  357  ; 
various  dysaesthesiae  of, 
probably  due  to  enteropto- 
sis,  288 ;  electrical  treat- 
ment of  atony  of,  251,  252  ; 
motor  functions  of,  58,  60, 
63,  64,  68,  128,  236,  237, 
240,  245,  246,  252,  254,  357 ; 
ptosis  of,  283,  285  ;  secre- 
tion, disorders  of,  60-68, 
127, 128,  129, 130,  236,  237, 
245,246,251,252,254,255; 
walls,  congenital  weakness 
of,  127  ;  washing  out,  252, 
255.  See  also  Atony,  gas- 
tric, and  Fermentation. 

Stomach-tube,  58,  68,  128. 

Stone  fruits,  242. 

Stools,  see  Faeces. 

Stories,  terrifying,  pernicious 
effects  on  children  of,  168. 

Storms,  sensitiveness  to,  78. 

Strawberries,  259. 

Struggle  for  life,  a  cause  of 
N.,  8,  10. 

Students,  N.  in,  11. 

Suasion,  moral ;  in  treatment 
of  neurasthenic  hypochon- 
driasis,  121  ;  little  effect 
on  fixed  hypochondriacal 


INDEX    OF    SUBJECTS. 


401 


phobias,  122.  See  also 
Reasoning,  psychotherapy 
by. 

Subalpine  health  resorts,  331. 

Sub-conscious  mental  opera- 
tions in  melancholia,  119. 

Succussion,  gastric,  57,  58. 

Sugar,  214,  225, 259,  262,  303, 
306,  361.  See  also  Carbo- 
hydrates. 

Suggestibility ;  of  children, 
160;  of  neurasthenics,  72, 
73,  74,  182. 

Suggestion,  hypnotic,  193, 
196-200. 

Suggestion,  non-hypnotic ; 
educational  use  of,  161, 162, 
164  ;  therapeutical  use  of, 
xi,  74,  118,  183,  185,  200 
-208,  351;  imparted  by 
various  hygienic  measures, 
183,  187,  199  ;  and  by  sur- 
roundings and  habits,  74, 
322 ;  compared  with  reason- 
ing, 194,  195,  196;  auto-, 
207,  208. 

Suicide,  in  genital  N.,100, 366. 

Sulking,  frequent  in  neuro- 
paths, 166. 

Sulphates,  ethereal,  in  urine, 
295,  296. 

Sulphates,  inorganic,  in  urine, 
296. 

Sulphur  lotum,  278. 

Sunshine,  action  of,  328. 

Suppositories,  276;  irritating-, 
292. 

Sweden,  N.  in,  11  (note). 

Swedish  movements,  343  ;  in 
treatment  of  constipation, 
271. 

Sweetbread,  262  and  note. 

Sweets,  264. 

Switzerland,  331,  332,  338. 

Sympathetic  system,  nerves 
of,  affected  in  N.,  2. 

Neurasthenia. 


Sympathy,  ill-regulated,  per- 
nicious effects  of,  74,  96, 
186. 

Symptomatic  treatment,  107. 

Symptoms  of  N.,  2,  38-89; 
fixity  of,  distinguishes  N. 
from  hysteria,  etc.,  3 ;  neces- 
sity of  ascertaining  their 
precise  nature  in  each  case, 
38,  176 ;  some  react  on 
general  condition,  xxv,  39 ; 
subjective  character  of,  39. 

Syphilis ;  as  an  exciting  cause, 
33  and  note  ;  treatment  of, 
an  exciting  cause,  33  (note) ; 
in  parents,  a  predisposing 
cause,  15 ;  neurasthenics 
with,  sometimes  imagine 
their  symptoms  due  to  loco- 
motor  ataxy  or  general 
paralysis,  111. 

"  Systems,"  injuriousness  of, 
179,  208,  210. 

TABES  dorsalis,  see  Loco- 
motor  ataxy. 

Tachycardia,  81,  82  ;  perma- 
nent, a  contra-indication  to 
mountain  climates,  331. 

Tact  required  in  examining 
neurasthenics,  39,  42,  206. 

Tapioca,  303. 

Tasks ;  good  for  children,  163  ; 
should  be  below  their 
powers,  163. 

Taste,  disorders  of,  87.          , 

Tea,  236,  239,  248,  263,  305  ; 
in  gout,  260  ;  prohibited  in 
insomnia  and  palpitation  of 
the  heart,  243  ;  and  in  hy- 
perchlorhydria,  253 ;  action 
of,  235. 

Teachers,  N.  in,  11. 

Teeth,  defective,  247. 

Temper ;  bad,  frequent  in 
neuropaths,  166  ;  often  the 

26 


402 


INDEX    OF    SUBJECTS. 


result  of  education,  167 ; 
irritable,  in  family  history, 
15  ;  in  schoolboys,  22. 

Temperature,  external ;  sensi- 
tiveness to,  78,  322. 

Temperature  of  body  ;  fall  of 
peripheral,  84 ;  internal, 
modified  at  first  by  high 
altitudes,  324. 

Temples,  headache  localised 
in,  46. 

Tenesmus,  vesical,  294. 

Tennis,  344. 

Tension,  arterial ;  high,  may 
be  accompanied  by  neuras- 
theniform  symptoms,  113 ; 
low,  xxi,  83,  89  (note). 

Terrors,  nocturnal,  168. 

Testes,  malformations  of,  98. 

Thermal  springs,  323. 

Thighs,  neuralgic  pains  in,  in 
genital  N.,  99. 

Thirst,  65,  67,  242. 

Timidity,  morbid,  71,  98,  100, 
163. 

Tinnitus  aurium,  87. 

Toast,  260,  263,  305,  306. 

Tobacco  ;  abuse  of,  a  cause  of 
N.,  30,  31,  36  ;  tendency  to 
abuse,  243  ;  use,  when  per- 
missible and  when  to  be 
forbidden,  243,  281,  282; 
action  of,  281. 

Tomatoes,  259,  264. 

Tone ;  muscular,  lack  of,  xxii ; 
arterial,  83,  89  (note). 

Tongue  ;  pain  in,  92  ;  trem- 
bling of,  in  general  paraly- 
sis, 112 ;  coated,  in  muco- 
membranous  colitis,297,305. 

Tongue,  calf's,  262. 

Topoalgia,  92,  111,  180. 

Towns,  large,  form  a  bad  en- 
vironment for  children,  147. 

Toxic  diseases  in  parents,  a 
cause  of  N.,  15,  16 


Toxic  substances,  a  cause  of 
N.,  30,  31,  32,  36. 

Toxins  due  to  fermentations 
of  chyme,  as  a  cause  of  N., 
127,  128. 

Toxins  due  to  faulty  meta- 
bolism, xix,  xx  and  note. 

Traumatic  N.,  34,  35,  53,  93, 
100-104,  115,  139;  due 
much  less  to  physical  than 
to  moral  shock,  102  ;  treat- 
ment, 368. 

Traumatic  neurosis,  the,  101. 

Traumatism  ;  a  cause  of  N., 
xviii,  34,  35,  36,  101,  102, 
130;  a  cause  of  enterop- 
tosis,  283. 

Travelling,  indications  and 
contra-indications  for,  335- 
338. 

Treatment ;  psychotherapeu- 
tic,  178  ;  dietetic,  209  ;  hy- 
drotherapeutic,  308 ;  cli- 
matic, 322 ;  by  exercise, 
339  ;  of  N.  of  women,  346 ; 
of  genital  N.,  363  ;  symp- 
tomatic, 107. 

Trembling,  77,  84  ;  of  tongue 
in  general  paralysis,  112. 

Trout,  217,  261. 

Tuberculosis  ;  — and  N.,  xx  ; 
as  an  exciting  cause  of  N., 
33 ;  in  parents,  a  predis- 
posing cause,  15,  16. 

Tumours,  cerebral,  differen- 
tial diagnosis  from  N.,  113. 

Turnips,  259,  264. 

Types  of  neurasthenics,  39-42. 

Typhoid,  as  a  cause  of  N .,  32. 

UNITED  States,  N.  in,  7, 8, 

41. 
Unworthiness,  false  ideas  of, 

in  melancholia,  119. 
Urea  ;  ratio  of  nitrogen  of,  to 

total  nitrogen  of  urine,  222, 


INDEX    OF    SUBJECTS. 


403 


223  ;  the  chief  end  product 
of  nitrogenous  food  kata- 
bolism,  223  (note) ;  excre- 
tion of,  increased  slightly 
by  massage,  353. 

Urethra ;  affections  of,  as 
causes  of  N.,  33,  97  ;  feel- 
ing of  burning  in,  99. 

Uric  acid,  222,  223  (note); 
diathesis,  predisposes  to  N., 
256  ;  diuresis  and  elimina- 
tion of,  259. 

Urinary  disorders  ;  in  N.,  88, 
89  and  note  ;  in  locqmotor 
ataxy,  111 ;  in  general  pa- 
ralysis, 112. 

Urine ;  history  of  nocturnal 
incontinence  of,  in  genital 
N.,  98;  analysis  of,  216, 
222,  223,  224,  295,  296; 
diminished  acidity  of,  233  ; 
signs  of  perverted  kata- 
bolism  in,  xvii,  88,  89. 

Uselessness,  a  cause  of  N.,  28. 

Uterine  appendages,  lesions 
of,  a  cause  of  muco-mem- 
branous  colitis,  292. 

Uterine  displacements,  xxii. 

Utero-ovarian  affections,  as  a 
cause  of  N.,35,36,94,97,132. 

Utilisation  of  food,  coeffi- 
cient of,  219,  220. 

VALERIAN,  extract  of,  307. 

Valerianic  acid,  a  product  of 
carbohydrate  fermentation, 
295. 

Vanity;  efforts  to  realise  whims 
of,  a  cause  of  N.,  28;  a  source 
of  self-involvement,  167. 

Varicocele,  xxii. 

Vaso-motor  system,  irritable 
weakness  of,  xvii,  xviii,  xx 
(note),  xxvi,  83,  84,  85, 
133,  134;  effect  of  food 
and  fasting  on,  134. 


Vaso-motor  theory ;  of  N.,  80, 
81,  133,  134 ;  of  transient 
albuminuria,  89  (note). 

Vegetables ;  the  best  source  of 
phosphorus,  232,  233;  in 
atonic  dyspepsia,  241,  248, 
261,  262,  263,  264  ;  in  gout, 
257,  259  ;  in  constipation, 
277  ;  in  muco-membranous 
colitis,  301,  306;  in  Ley- 
den's  diet,  360 ;  in  Bins- 
wanger's,  361.  See  also 
generic  names. 

Vegetarianism  in  gouty  N.f 
not  advisable,  257. 

Venereal  diseases,  as  causes 
of  N.,  33,  97,  132. 

Vermicelli,  261,  303. 

Vertebral  column,  see  Spine. 

Vertex,  headache  localised  in, 
46. 

Vertigo ;  a  frequent  symptom, 
75 ;  accompanying  head- 
ache, 47  ;  characters  of,  76, 
77  ;  rotatory,  rarely  obser- 
ved, 76 ;  sometimes  resem- 
bles Meniere's,  76 ;  some- 
times cerebellar  vertigo,  77 ; 
accompanied  (rarely)  by 
narrowing  of  field  of  vision, 
87  ;  usually  of  central  ori- 
gin, 75,  76 ;  probably  some- 
times due  to  vaso-motor 
disturbances  in  brain,  85, 
134 ;  sometimes  to  consti- 
pation, 265 ;  gastric  theory 
of,  75, 127,  128  ;  in  cerebro- 
spinal  N.,  93  ;  little  marked 
in  spinal  N.,  94  ;  in  N.  of 
women,  95 ;  in  traumatic 
N.,  103 ;  causing  fear  of 
locomotor  ataxy,  111 ;  in- 
creased by  excessive  smok- 
ing, 281 ;  in  muco-membra- 
nous colitis,  297 ;  hydro- 
therapeutic  treatment  of, 


404 


INDEX    OF    SUBJECTS. 


319 ;  frequent  attacks  of,  a 
centra-indication  to  high 
altitudes,  331. 

Vexation  ;  a  cause  of  N.,  25 ; 
vexation  of  self-esteem,  28. 

Vichy  water,  250. 

Villacabras  water,  291. 

Viscera  ;  innervation  of,  af- 
fected by  N.,  2  ;  vaso-motor 
disturbances  in,  85 ;  pains 
in,  supposed  to  be  a  contra- 
indication to  Weir  Mitch- 
ell's treatment,  362. 

Visceral  derangements,  a  sup- 
posed cause  of  N.,  4. 

Vision ;  rapid  fatigue  of,  86, 
93,  103  ;  narrowing  of  field 
of,  86,  87. 

Voluntary  movements,  ex- 
hausting to  some  neuras- 
thenics, 341. 

Vomiting  ;  absent  in  simple 
hyperchlorhydria,  65 ;  pres- 
ent in  Reichmann's  disease, 
66,  67,  68 ;  frequently  ac- 
companies vertigo,  76;  in 
traumatic  N.,  104. 

WAKING,  exhaustion  on, 
128. 

Walking;  a  valuable  exer- 
cise, 152,  157,  344 ;  in  pure 
cerebrasthenia,  189;  after 
lunch,  in  severe  gastro- 
intestinal atony,  247 ;  very 
tiring  in  N.  of  women,  95. 

Washing  out ;  stomach,  252, 
255  ;  intestine,  300,  301. 

Wasting ;  common  in  N., 
211 ;  but  far  from  constant, 
212 ;  in  severe  form  of 
gastro-intestinal  atony,  59 ; 
little  or  none  in  slight  form, 
61 ;  in  continuous  form  of 
Reichmann's  disease,  67  ;  a 
cause  of  tachycardia,  82 ; 


in  N.  of  women,  96,  346, 
347,  359  ;  in  neurasthenics 
with  enteroptosis,  284. 

Water,  should  a  gouty 
neurasthenic  drink  much  ? 
259. 

Watering-places,  in  muco- 
membranous  colitis,  301. 

Waters,  mineral,  for  table, 
242,  263,  306. 

Waters,  natural  aperient, 
268,  278,  290,  291,  299. 

Weakness,  irritable,  of  nerve 
elements,  N.  defined  as,  2, 
308;  in  heart's  action,  83; 
in  vaso-motor  system,  134  ; 
in  N.,  minor,  xvi. 

Weakness,  see  Asthenia. 

Weighing ;  of  food,  216,  217, 
229 ;  of  patient,  216,  221. 

Weir  Mitchell's  treatment,  94, 
185,  249,  347-360 ;  Burkart 
and  Leyden's  centra-indica- 
tions, 362;  necessity  that 
the  patients  should  under- 
stand the  end  pursued,  362. 

Westphal's  sign,  111,  206  and 
note. 

Wet  pack,   309,   312;     with 

•  friction,  309,  314 ;  dripping, 

without  friction,  310,  314; 

abdominal     or     epigastric, 

320,  321. 

Whiskey,  359. 

Whistling  in  ears,  76,  87. 

Whiting,  261. 

Will ;  enfeeblement  of,  70,  72, 
95,  119,  160,  181,  186,  342, 
346,  347,  348,  359;  see  also 
Aboulia ;  child's,  often 
broken  by  too  rigid  rules, 
148 ;  education  of,  163, 164, 
168;  treatment  to  restore, 
181, 184,  185,  186, 188,  195, 
202,  203,  359. 

Wind,  sensitiveness  to,  78. 


INDEX    OF    SUBJECTS. 


405 


Wine,  235,  242,260,  263,  359, 
361. 

Wines,  digestive,  250. 

Women;  less  subject  than 
men  to  N.,  10. 

Women,  N.  of,  51,  73,  93,  94- 
97,  249,  342,  346,  347; 
treatment  of,  347-362. 

Work,  excess  of,  an  exciting 
cause  of  N.,  36.  See  also 
Overpressure. 

Work,  incapacity  for ;  in  over- 
driven schoolboys,  22 ;  in 
N.,  49,  70, 72,  93,  104,  115, 
117,  128 ;  climatic  treat- 
ment of,  330,  334. 


Working  men,  N.  in,  11  and 

note. 
Worry;   a  cause  of  N.,  xix, 

20,  33,  34,  180;    mode  of 

action  of,  xix,  xx.    See  also 

Cares. 
Writer's  cramp,  77. 


YAWNING,  in   schoolboys, 
22. 


ZANDER'S          mechanical 

gymnastics,  343. 
Zones,  hyperaesthetic,  78. 


INDEX    OF    AUTHORS. 


AKERLUND,  Swen,  293. 
Allbutt,  Clifford,  ix  (note),  xx, 

11  (note). 
Anjel,  81,  133  and  note,  134, 

135. 
Axenfeld,  ix  (note). 

BAILLARGER,  108. 

Balland,  217. 

Ballet,  xv,  xvii,  xviii,  xx, 
xxii,  xxiii,  xxiv,  xxv,  49 
and  note,  100  and  note,  116, 
(note),  359. 

Baumann,  296. 

Beard,  vii,  ix  and  note,  1,  3, 
6,  7,  32,  41,  47,  49,  75,  77, 
90,  92,  97,  120,  132,  135, 
244,  335,  338,  363,  367. 

Beau,  126,  129. 

Benedikt,  368. 

Beni-Barbe,  317. 

Berger,  32. 

Bernheim,  192  (note),  195, 
197,  198. 

Biernacki,  302. 

Binswanger,  360. 

Blocq,  P.,  92. 

Blondel,  300. 

Bottey,  F.,  314. 

Bouchard,  64,  127,  245,  246, 
258. 

Bouchut,  vii,  91. 

Bourget,  299,  300. 

Boussingault,  230,  232. 

Bouveret,  ix  (note),  xxii,  28, 
40,  51,  55,  60, 61, 62,  63,  74, 
77,  82,  178,  203,  245,  251 
and  note,  284  and  note,  320, 
338,  359. 

Breal,  151. 

Bretonneau,  278,  299. 

Brissaud,  ix  (note),  124  and 
'  note. 


Brouardel,  ix  (note),  102. 
Broussais,  126. 
Burkart,  360,  362  and  note. 
Byasson,  231. 

CAMPBELL,  Harry,  xvii. 

Camus,  xxvi,  178  (note),  195. 

Cantani,  257. 

Cautru,  234. 

Cerise,  vii. 

Charcot,  ix  and  note,  24,  33, 

41,  44,  45,  47,  75,  86,  92, 

101,  102,  335,  359. 
Chossat,  230. 
Combe,  297  (note),  303,  304. 

DANA,    ix    (note),    xix,    33 

(note). 

Dejerine,  xxvi,  178  (note),  179. 
Deville,  Sainte-Claire,  149. 
Dieulafoy,  xvii. 
Dominici,  299,  302. 
Dowse,  ix  (note). 
Drummond,  xxvi,  xxvii. 
Dubois,  xxvi,  106  and  note, 

107, 108,  109, 139,  178, 179, 

195. 

Duchenne,  365. 
Dukes,  89  (note). 
Dutil,  ix  (note). 

EDWARDS,  293. 
Egger,  325  and  note. 
Elden,  197. 

Erb,  135,  251  and  note. 
Erichsen,  101. 
Eulenburg,  188. 

FALRET,  108. 
Fere,  135. 

Fleiner,  266  and  note, 
de    Fleury,    ix    (note),    137 
(note),  139,  200  (note),  311. 


INDEX    OF    AUTHORS. 


407 


Forel,  197. 
Forster,  230. 
Fournier,  33. 
Franck,  vii. 
Freud,  123  (note). 
Froussard,  272  (note). 


GALEN,  6, 126. 
Galton,  F.,  23  and  note. 
Gautier,  A.,  214  and    note, 

217,  219  and  note,  220,  230, 

231,  235. 
Gautrelet,  213. 
Geuth,  259. 
Gilbert,  ix  (note),   233,  299, 

302. 

Gilles  de  la  Tourette,  ix  (note). 
Gle~nard,  xxii,  132,  213,  266, 

282  and  note,  283,  284  and 

note,   285,  287,    289,    290, 

291. 

Godlewski,  ix  (note). 
Goodhart,  170  (note). 
Grasset,  192  and  note,   194, 

195  (note). 
Grawitz,  303. 
Guyau,  149  (note),  159,  161, 

165. 


HALLIBURTON,  223 

(note). 

Hamilton,  32. 
Hartenberg,  123  (note). 
Hasse,  25. 
Hayem,  129,  245. 
van  Helmont,  126. 
Helvetius,  142. 
Henitz,  259. 
Herzog,  63  and  note. 
Hippocrates,  210. 
Hoppe  Seyler,  303. 
v.    Hossling,   10   and    notes, 

25. 
Huchard,  ix.  (note). 


JANET,  P.,  117  and  note, 
otcyko,  Mdlle.,  136  (note), 
oulie,  232,  233,  234. 

KEMMERICH,  230. 
Kitagawa,  293. 
Konig,  217. 
Krafft-Ebing,  25,  97. 
Krauss,  303. 
Krishaber,  vii,  92. 
Krysinski,  293. 

LABBE,  223. 
Laboulbene,  293. 
Lagrange,  132,  153  and  note, 

213,  343  and  note. 
Lange,  107,  108,  109. 
Lecorche,  259. 
Lee,  xix  (note). 
Legrand  du  Saulle,  203. 
Leube,  54,  56,  63,  251. 
Levillain,  ix  (note). 
Levy,  207  and  note. 
Leyden,   63   and    note,    101, 

360,  362. 
Liddell,  101. 
Lyon,  297  (note),  303  (note). 

MAIRET,  231. 

Marcel,  223. 

Martinet,  227  and  note,  233 
(note),  234. 

Mathieu,  ix  (note),  55, 62,  63, 
260  (note),  266  and  note, 
276  (note),  290,  297  (note), 
300. 

Mazeran,  272  (note). 

Melchior  de  Vogue,  27. 

Meniere,  76. 

Meynert,  25. 

Mitchell,  Weir,  vii,  ix  (note) 
94,  95,  96,  97  and  note, 
185,  212,  239,  244,  249,  342, 
347,  348,  349,  352,  353, 
355,  356,  358  and  note, 
359,  360,  362. 


408 


INDEX    OF    AUTHORS. 


Mobius,  148,  188  and  note. 

Moleschott,  217. 

Monneret,  vii. 

Montaigne,  x. 

Morris,  101. 

Mosso,  19,  49,  133. 

Miiller,  ix  (note),  10  (note), 

325  (note). 
Muncke,  303. 
Munk,  258. 

NESTEROFF,  22. 
v.  Noorden,  277. 
Nothnagel,  293. 

OERTEL,  345. 
Oppenheim,  101. 

PAGE,  ix  (note),  101. 
Pagniez,    xxvi,    178    (note), 

195. 

Pascal,  163. 
Petren,  11  (note). 
Philippe,  49  and  note. 
Pitres,  77,  86,  92. 
Playfair,  ix  (note),  359,  362. 
Poehl,  302. 
Posternak,  233. 
Priessnitz,  317. 
Prince,  Morton,  xxiv,  xxv. 
Proust,  v,  260  (note). 
Putnam,  101. 

RANKIN,  Guthrie,  xxvi. 
Regis,  34. 

Reichmann,  64,  66,  255. 
Renan,  151. 
Robin,  88,  231. 
Rosenheim,  303. 
Roux,  276  (note). 
Roy,  120  (note). 
Rubner,  215,  219,  303. 

SAINTE  -  CLAIRE       DE- 

VILLE,  149. 
Saulle,  Legrand  du,  203. 


Savill,  ix  (note). 

Savory,  101. 

Schmidt,  293. 

Schondorff,  259. 

Schultz,  368. 

Senator,  303. 

Seyler,  Hoppe,  303. 

Spencer,  Herbert,  143  and 
note,  146,  147  and  note, 
171,  172,  173,  174  (note). 

Springer,  232. 

Stiller,  63  and  note. 

Stoll,  6. 

Striimpel,  178. 

Sydenham,  6. 

Syme,  101. 

THOMSEN,  101. 

de    la    Tourette,    Gilles,    ix 

(note). 

Treves,  136  (note). 
Trousseau,  269, 270  and  note, 

271,  278,  281. 

UFFELMANN,  258. 
Ultzmann,  97,  365. 
Urquhart,  xviii  (note). 

VALLEIX,  78. 
Viault,  325  and  note. 
Vibert,  102. 
Vigouroux,  213. 
Vogue,  Melchior  de,  27. 

WALTON,  101. 
Weber,  134  and  note,  324. 
Weiske,  303. 
Westphal,  86,  101. 
Whytt,  6. 
Wicke,  303. 
Winter,  129. 
Winternitz,  302,  367. 

ZIEMSSEN,-  ix  (note),  77, 
251  and  note,  327,  338. 


Henry  Kimpton,  13,  Furnival  Street,  London. 


DATE  DUE 


_4inBaiByBSLja 


-NGV-4 

JUl 


21995 

m 


INTEOINU.S 


A     000503427     7 


UC  IRVINE  LIBRARY 


3  1970  01663  9350 


Gilbert. 
Neurasthenia 


Ballet,   Gilbert. 
Neurasthenia 


B191n 
1909 


s 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


